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Artillery Row

It’s hurting but it’s just not working

The government’s Covid-19 cure is worse than the virus

A long month ago in 10 Downing Street, before public opinion (and Jeremy Hunt) turned against him, Sir Patrick Vallance was painstakingly clear that group immunity while sheltering the vulnerable is the only game in town, but that we should flatten the curve (“squash the sombrero”) so that the NHS would not be overwhelmed.

Yet faced with murky data, a clamouring press and terrifying reports from Italy, the current lockdown was hurriedly declared, in order to buy time for the NHS to build further capacity for the approaching storm. Given the paucity of data available when the decision was made, and how things could have gone, perhaps the government did the right thing. It has, indeed, used the time to create impressive capacity, and can now assert that the UK does have capacity (both hospital beds generally and ICU beds and ventilators in particular) for whatever comes our way.

But we’re still locked down. Like many things in life, it turns out that lockdown was much easier to get into than to get out of. It also turns out that the reasons for going in seem to be wildly different to the reasons for coming out; the key that locked the door doesn’t unlock it.

With no change in the science (if anything, it now points to dramatically lower mortality from Covid-19 than had been thought), but with the clear support of public opinion in favour of lockdown, we are now shut in our houses with schools closed, civil liberties suspended and the economy in a coma. And the cabinet is in a pickle. It sounds a lot like “mission creep.”

So how do we get out? Dominic Raab came up with five tests to be met before lockdown can be released. Let’s go through each of them in turn.

1) Evidence that the NHS can cope

Only 19 patients were admitted to the new 4,000-bed Nightingale hospital in London ExCel over the four-day Easter bank holiday weekend, and, up to 20 April (a fortnight after being opened) it had still only admitted 41 patients in total.

I am not being snarky. Matt Hancock was clear that the NHS was “hoping for the best but preparing for the worst” – entirely properly. But it does suggest that we’re fine.

Here’s a chart showing the decline in hospitalised patients with Covid-19 (that bears repeating – not slower growth, decline):

It seems pretty hard to imagine that the NHS isn’t going to cope.

2) Sustained/consistent fall in daily death rates

Deaths will lag infections by around three weeks, so this is an odd metric to judge when infection-control measures should be lifted, but below is the output for UK deaths from the Imperial College model (yes, the famous one) using the latest NHS data.

As has now been widely reported, deaths have been declining in the UK since 8 April, but we know from Italy’s experience that the right-hand shoulder of the curve will be shallow (victims can be kept ventilated for long periods before succumbing).

3) Evidence that the rate of infection is decreasing

I am sceptical about the number of “cases” (positive test results) announced each day at 10 Downing Street: around a third of tests generally come back positive, so by tracking their trajectory you are really just tracking how quickly testing is being rolled out.

A better (and earlier) lead indicator of cases is the daily change in Covid-19 hospital inpatients shown above; and an even earlier lead indicator is the number of potential patients calling 111 or 999 (or using 111 online) reporting Covid-19 symptoms, which has been in sharp decline for weeks now including among the most vulnerable age-group:

Clear evidence of a dramatic and sustained decline in cases.

4) Confidence that supplies of testing and PPE are able to meet demand

I am a voice in the desert, but it seems very unlikely that testing is a way out of this. Adam Kucharski from the London School of Hygiene & Tropical Medicine has calculated that “if mass testing [95% of population] were feasible, it would probably need to be biweekly, not weekly.” Can this be realistic? And would it really save lives anyway?

Targeted, likely app-based, contact-tracing would not only mean continued invasion of our civil liberties, but it is doubtful that it would slow virus progression or is even viable where the epidemic is now so widespread, as the deputy chief medical officer, Jenny Harries, has patiently explained at the 10 Downing Street presentations. It might have worked two months ago, and might be a great strategy for future small, localised outbreaks but it really doesn’t sound like a route out of our current fix. Even proponents believe it would take 100,000 trained contract-tracers constantly following up on app-based notifications, and by the time that is up and running this epidemic will simply have run its course.

I will mention only parenthetically that the above all assumes that the current swab-tests actually work reliably – which they don’t. Technically: most are highly specific (few false-positives) but have dreadful sensitivity, not uncommonly producing up to 30% false-negatives. As a patient, they’re useful; for contract-tracing of such an infectious virus, they’re completely useless.

Graham Stewart’s excellent recent article has discussed PPE. But that is the “supply” side. The fundamental thing about PPE is point 3 above, the “demand” side: given the sustained decline in cases coming into hospitals, logically less PPE kit should be needed from now on.

5) No risk of a second peak

This is the head-scratcher. A de-squashed sombrero regains its shape to some extent, but it might depend on what we call a “peak”. Tellingly, the First Secretary has now started referring to a “spike” in cases, which sounds more pronounced (let’s hope it doesn’t happen in flu season); but perhaps we are lost in semantics.

I don’t think anyone (certainly not Chris Whitty or Patrick Vallance) believes that suppression can lead to elimination.  And please, don’t kid yourself about vaccines, we have been looking for a vaccine for SARS (a similar coronavirus) for 18 years (a fascinating story in itself). A cousin has been an HIV vaccine researcher since the 1980s. These solutions are a long time coming.

Our best evidence for the likelihood of a “proper” second spike will be Sweden. Their peak in deaths and cases also appears to have passed, with no lockdown but simply good hygiene and sensible social distancing. Agonisingly, their pubs are still open. If the virus simply burns out there (William Farr documented over two centuries ago how epidemics simply come and go), it is difficult to imagine that it would not have done the same here. Put crudely: it’s the same virus, we’re the same species.

Those are the five tests, and I’d say we’ve met all of them.

But for me the outrageous point of the Foreign Secretary’s speech was a sin of omission, a dog that didn’t bark: an extra, missing condition to trigger release of lockdown. Namely evidence that the lockdown itself is causing significant deaths. Let’s look at then.

A test for the government

Each Tuesday, the ONS release granular data on deaths in England and Wales, and it is now clear that there is a significant second, additive, curve of excess non-Covid deaths; “lockdown deaths”, if you will. This is likely a combination of late presentation at hospital (through fear of infection) for cardiovascular issues (including stroke), with cardiac admissions down dramatically throughout the land. The scale of deaths is now alarming both in itself and in the context of Covid-19. Chris Whitty first referred to this second set of deaths over a month ago.

Now that we have NHS capacity, it isn’t clear that the lockdown is saving any lives at all; rather, it appears that the lockdown is already costing thousands of lives.

We should expect to see the most pronounced effect where the ill and elderly are most concentrated, and this is just what we see in the ONS’s breakdown of deaths in care homes, where the Covid-19 deaths are far fewer than you’d imagined from the press.  But the effect of lockdown is passing through care homes like an angel of death:

How can it be clearer?

Unlike covid-19, this is a killer we have created and that we can do something about.  Boris called the first lockdown because the science pointed that way at that time, and the First Secretary, Dominic Raab, presumably renewed it because Boris was ill. But whoever renews the lockdown again would simply have blood on their hands.

The political reality is that the government has boxed itself in by allowing policy to be dictated by opinion-poll; it bowed to pressure to copy everyone else (apart from the free Swedes), then had to scare the public into compliance with the lockdown they’d demanded, and now the public is indeed scared. But look purely at the likely toll: even if declaring lockdown was originally the right move, leaving it in place can certainly be the wrong move. Protect the vulnerable, sure, but lift the lockdown: back to Plan A.

We should now be emerging, pale and cowed, into a slightly diminished world and wondering how to pay for all this.  Instead, we are waiting for the public to stop being afraid of something they were purposefully terrified with, and for the furloughed to have caught up on box-sets sufficiently that 0% work for 80% wages no longer seems like a great deal.

Lockdown: when the fun stops, stop.

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