Coronavirus: no easy options

Tuesday 7 April 2020  

There is something distinctly Soviet in the way the news on the prime minister's health has been managed. After nearly a week of rumours, when aides were insisting that Johnson was suffering only "mild symptoms".

When, finally, it was conceded that the prime minister had not been able to shake off his illness, we were told that he was being referred to hospital for "testing", while he remained in "good spirits" and in full control of the government.

After spending a "comfortable night" we heard little more until it emerged that he was to spend a "second night" in the hospital. Only hours later he was "on oxygen" and then came the news that he was in intensive care.

In retrospect, having not recovered from his illness, it is clear that the prime minister on Monday was not at all well. The claim that he was being referred to hospital merely for "testing" was quite obviously (even at the time) a fiction.

This is important because, at a time of crisis when the government is demanding the active participation of the population in its measures, trust is an essential element. And here we have a situation where the official news is quite evidently being managed, and people are being kept in the dark.

Such an action, of course, transcends the fate of an individual. Johnson, at best, is a divisive character and there are many – including this writer – who cannot stand the man. It would be hypocritical to state otherwise.

But, at the height of an epidemic, continuity of leadership tends to be important and therefore, the health of the prime minister is a matter of legitimate public concern. It is important that the public is not kept out of the loop.

Even the Guardian retails that some Conservative MPs are worried that Downing Street's evasiveness on the seriousness of the prime minister's condition "will undermine trust in what they say going forward".

And whether stated or not, it is apparent that Johnson is not fit to lead the government at this stage. Even if he was well enough to read his papers and take briefings, the judgement of a sick man must be questionable. Thus, whether we like it or not, the de facto deputy prime minister, Dominic Raab, must take control.

Some are questioning whether the substitution would be an improvement, or whether we will be in the hands of a second division politician who is even less capable than the man he replaces. Here, only time will tell but it is also the case that, in the current circumstances, it would be very difficult for any leader to excel.

That much, I've already noted, conceding yesterday that the mess in which we find ourselves is not entirely of the prime minister's making. And that there are stresses in government as to which actions should be taken is being widely conceded, even by the likes of the Telegraph.

The media, though, has the unfortunate habit of focusing on the here and now, highlighting the interplay of personalities in government, or advising ministers. In so doing, they tend to treat the epidemic response as if it had been devised and executed by the current players.

In this, there seems to be no recognition that the fightback against Covid-19 requires the commitment of the full apparatus of the state, a giant clunky machine with so many moving parts that it is quite beyond the control of the prime minister or those advising him. Most, in fact, will have only a vague idea of the extent of the machine, and very few (if any) have a complete grasp of how it works.

Tracking back the current policy, we have identified its genesis in the Blair years, with most of the components of the current policy having been decided then, and recognisable in the actions and responses of this government. That is how it always is.

Complex policies cannot be devised on the hoof and while prime ministers like to give the impression that they are in charge and in command of events, in events of this nature they have little option but to fall back on the plans devised during the tenures of their predecessors.

That is not to say that Blair, during whose term the current policy was initiated, had any direct part to play in its formulation. No doubt, he was informed of what moves were being made to devise a pandemic preparedness plan, but he would have had no more coherent things to say about it than might have Cameron when his turn came to preside over amendments and updates.

Inevitably, with such plans, the only real way they can be tested is to implement them and, as I observed previously, Johnson has drawn the short straw. It is not his fault that that plan has been found to be wanting, based on false assumptions and proposing actions which, quite obviously, are politically untenable.

Being saddled with a plan that doesn't work is one thing though. Knowing what to do about it is quite another, especially as the automatic response of officials will be to deny any flaws and to defend the "plan" against precipitous change.

It is very clear though that Johnson was forced to confront the political consequences of a "do nothing" policy, riding out the storm until a vaccine became available. Thus, he ordered a rushed "lockdown" strategy, cobbled together on the hoof, with no very clear idea of the implications and even less of an exit strategy.

In the nature of the media though, obsessed as it is with personality politics, there is only one item of news at the moment, dominating the front pages of all the national newspapers and taking the lead with the broadcasters. And that is the admission of the prime minister to intensive care.

Of far greater importance, even in the shorter term, however, is the management of the lockdown, and the decisions on when restrictions can be lifted, before people start to rebel and the damage to the economy becomes overwhelming.

With the cases having reached 51,608 and the death toll having soared to 5,373, there are no indications as yet that we are anywhere near a peak in the current phase of the epidemic. And if it is not for Johnson to decide when to take action, it will be down to Dominic Raab, who will be under exactly the same constraints as his fallen leader.

To an extent, this points up the irrelevance of that man at the top. These are not grand Churchillian days, where the fate of the nation rested on the fortitude of one man deciding that Britain would stay in the fight, whatever the odds, rejecting the siren calls to make a deal with Herr Hitler.

In this event, surrender is not an option so the fight back is a given. But how that is achieved lies in the hands of the technocrats, beyond the ken of politicians, on whose advice the prime minister must largely rely.

Whether Johnson or Raab, though, there are no easy options and no single master stroke that will bring us victory against this invisible enemy. If and when the restrictions are lifted, we will almost certainly see a recrudescence of the illness yet, for every day the restrictions are in place, the economic damage multiplies.

The ultimate resolution to this crisis comes only when an effective vaccine is produced and administered, the development of which lies entirely outside the control of the prime minister. Unless he has the courage and understanding to realise that he has been misled by his officials and experts, and has been sold the wrong plan for this disease, all he can hope to do is embark on a programme of damage limitation.

In this context, "limitation" is in itself limited. The emphasis will be on the word "damage" and this is set to be substantial, whatever action is taken. The only trade-off available is whether that damage should be expressed in blood or treasure or, more likely, both.

There is a chance that a change of tack, with a real commitment to "test and trace", could make the difference, but all the indications are that the health establishment will block any such move.

And if Johnson showed no sign of understanding the issues, there is no likelihood of Raab proving any better. Between a prime minister, potentially unconscious under heavy sedation in intensive care, and his (so far) healthy deputy, there is very little difference. As long as we have our present system of government, it wouldn't make an awful lot of difference if we had a zombie at the helm.

That much, we need to take on board. The opportunity to decide our fate came and went fifteen years ago, and we are currently prey to decisions made then, which were neither scrutinised nor challenged. As this epidemic progresses, therefore, the prime minister isn't the only casualty. Long before he succumbed to the virus, the policy was already in intensive care. It is unlikely to recover.

Richard North 07/04/2020 link

Coronavirus: the wrong disease

Monday 6 April 2020  

Spending £350 billion to prolong the lives of a few hundred thousand mostly elderly people is an irresponsible use of taxpayers' money, wrote Toby Young at the end of the month.

Johnson, of course, was too late to have benefitted from the lockdown to which Mr Young so heartily objected (and still does), arguing that it is an overreaction. He asserts that the government should end it as soon as possible and encourage people to return to work. Social distancing measures, he says, should be limited to the elderly and those with underlying health conditions.

Young's original article was actually published four days after the Great Leader had been reported positive for coronavirus, after suffering symptoms for the previous 24 hours. But, after a period of self-isolation and "working at home", we learn that he has been admitted to hospital as a "precautionary step", for routine tests.

If one was to embrace the hard logic of Young's position (assuming we can take his calculations at face value – which is something I will address shortly), one assumes that we should write off the prime minister, as the cost of treating him will undoubtedly exceed the notional value of a person of his age.

Like the rest of the 230,000 theoretically saved by government intervention, he should be written off and allowed to die. After all, there is no shortage of applicants for the position of prime minister, so there should be no particular problem in filling the post (once the accommodation has been disinfected).

If this is taking the argument to extremes, it does nevertheless point up the difficulties of taking a strictly economic view of an event such as an epidemic. It is all very well applying comparative cost assessments to deaths occurring in isolation but an epidemic is a very public event, involving large numbers of people.

That makes it a political event and, even if it did make sense to assess the economic implications of taking action, the "do nothing" response which Young advocates is simply not tenable. At times of crisis, when people are exposed to great peril (real or perceived), the government is expected to act – at whatever the cost. If it didn't, it would very quickly become an ex-government as people took their own actions – which might not exclude violent overthrow of the denizens of No 10.

That is the point that Young misses. Political events have their own rules, as we recall from Jean-Claude Juncker who, in the aftermath of the 2008 financial crisis, wistfully declared, "We all know what to do, we just don't know how to get re-elected after we've done it". What makes economic sense (assuming it does) it not always an option.

However, in making an economic case, Young seems to assume that his "do nothing" stance is without cost. But, as we saw in the early days of this epidemic, with government havering about whether to take action, people did start to take their own actions.

We had a number of firms instruct their staff to work at home, football clubs decided to abandon fixtures, leaving the football authorities to abandon the season, and Formula 1 then cancelled its races. Universities started shutting down, as did schools and more and more enterprises ceased to operate as staff and managements voted with their feet.

Thus, the clinical picture that Young paints, with nice, neat divisions between courses of action, simply doesn't exist. The alternative to the government not imposing a lockdown would have been chaotic, unofficial action with a drastic economic impact, and serious implications for public order- while the spread of virus continued.

Even then, we have to consider the arithmetic. Like most amateurs in the field, Young has a naïve respect for the "modellers" and quotes with reverence Neil Ferguson's figure of 230,000 lives saved, on which he bases his economic assessment.

The mistake here, of course, is in treating the epidemic as a single event. Yet, as we have seen, it comprises multiple outbreaks at different stages, with some hotspots, the largest of which are in London and the West Midlands.

Simply taking out of circulation the elderly and those with underlying health conditions (even if it was possible) would mean a far more rapid spread of the virus, with multiple hotspots developing throughout the country. And while the illness is fatal mainly to elderly people and particularly those with underlying conditions, that is not always the case.

One wonders, therefore, whether Mr Young really thinks that people would go calmly about their lives as the epidemic ripped through the country, with the media recounting stories of hospitals overwhelmed, as health staff fell victim to the virus and the government daily announced a death toll soaring up to the hundred thousand level, and then doubling.

But then, as one might recall, Ferguson's estimate of 230,000 is not the only figure in town. The government itself has cited as many as 750,000 deaths and any estimate is precisely that – an estimate. Which government is going to have the nerve to sit tight and test the accuracy of the modelling, and put its money on Ferguson being right?

Then, there are the dynamics of epidemics to be considered. Given that it is still between 18 months to two years before a vaccine is administered to the population, the virus has ample time for second helpings, and even third.

One might recall that the 1918 "Spanish flu" epidemic lasted until 1920 – three years in all. Given three years to rampage, it is unlikely that this coronavirus would obediently stick to a quota of 230,000. What are the chances of a government surviving in that event?

In the real world, therefore – the world in which people exist and even prime ministers are mortal – Young's thesis is absurd. It is simply not a viable political proposition.

What one might also say is that, like so many of his ilk, he misses the bigger picture – lacking any understanding of what could have been. Increasing numbers of voices can be heard advocating the "test and trace" option for controlling the epidemic and I would be happy to argue the case that if this had been adopted right from the very start, the government might not have had to impose a nation-wide lockdown.

The costs to which Young objects, therefore, might be more accurately attributed not to the lockdown, per se but to the failures of successive governments to plan properly for an epidemic, and their willingness to allow the public health system in this country to decay.

If there is a lesson to learn, this might be it. There is nothing to say that Covid-19 is the only epidemic this nation will suffer. The growth in international air traffic and the mobility of the world's population (to say nothing of its growth), might make pandemics a routine event.

Thus, Covid-19 might actually be our wake-up call. But, as it is, theoretically it could be worse and, if from this emerges a better appreciation of what it takes to fight such epidemics and, as Pete points out societal changes to allow that to happen, the money spent will not have been entirely wasted.

For my part, I'm beginning to get to grips with this issue. I would not say I'm there yet as the last time I looked at the epidemiological system for dealing with a communicable disease – for my PhD thesis – it took me five years.

However, I am tending to the view that the first mistake in a fatal cascade started with the promulgation by the World Health Organisation of the 2005 International Health Regulations.

It was these which, for the first time, specifically listed pandemic influenza and Severe Acute Respiratory Syndrome (SARS) as potential "events of international public health concern". This formal status required member nations to "develop, strengthen and maintain… the capacity to detect, assess, notify and report" these diseases, and then to the develop "the capacity to respond promptly and effectively to [the] public health risks".

This led to the rash of the preparedness plans produced by members, including the UK, then under the Blair government, supposedly based on WHO guidelines. Where it all went wrong, in my view, is that members were allowed to produce influenza plans and use them as the template for dealing with SARS which, as it now transpires, demands a very different approach.

To that extent, we might have the right plan – for influenza – but it is being used to fight the wrong disease. Covid-19 is not influenza - it is a SARS. And as we record 47,806 cases and 4,934 dead, that represents the true failure, and why we are now having to embark on costly lockdowns.

There were plenty of other mistakes, not least the EU's European Centre for Disease Prevention and Control reporting on 14 February (by which time the UK had reported nine cases) that, "the risk associated with SARS-CoV-2 infection for the EU/EEA and UK population is currently low".

Elsewhere, one might argue that the public health profession lost its way, but that is another, longer story. As it stands, it may be of small comfort to the prime minister that, as he defies Mr Young's spending constraints, the mess we're in is not entirely of his making.

Richard North 06/04/2020 link

Coronavirus: the smoking gun

Sunday 5 April 2020  

It is a cynical but perhaps accurate observation on the ways of the media that the best way for government to keep a secret is to publish it in an obscure document, and then post it on the internet without bothering to tell anyone it exists. The media will never bother to come looking and, unless some enterprising hack "reveals" it, the secret will remain to the end of time.

That much can be said for the reasons why the government did not prepare a comprehensive testing programme as part of the preparations for the Covid-19 epidemic that is now upon us, and for its refusal to carry out tracing and isolation of contacts.

Thus, while the media puzzles over the reason, a clear statement of the rationale for its actions has actually been published and can be found in its "Scientific Summary of Pandemic Influenza & its Mitigation ", produced in 2011 by the Cameron coalition government.

The Summary backs up the 2011 Strategy which became finalised in the 2014 version. This is the plan currently in force and forms the basis of the government response.

The fact that the "scientific summary" document even exists, however, is wonderfully ironic in this post-Brexit world, as it was produced and prepared in accordance with Decision No 2119/98/EC of the European Community, later augmented by Decision No 1082/2013/EU.

The document itself comes with "Underpinning Evidence Base components", conveniently listed here by the EU's European Centre for Disease Prevention and Control (ECDC). The fact that it is to be found on the EU's Europa website almost certainly guarantees protection from media curiosity.

As to the contents of the document, the "smoking gun" can be found on page 7, under the heading: "Mitigation strategies". This starts with the reasonable statement that, "because a novel influenza viral strain could arise at any point in time and in any location; it is not considered feasible, at present, to prevent such a strain occurring in the first place".

It goes on to say that it "is also considered highly unlikely to be able to “contain” such an outbreak at source, which would most likely be overseas, perhaps in Southeast Asia based on historical analyses". As would most likely be the case with a newly-arising pandemic that was spreading through the UK, it then says, "multiple and parallel cases of infection would have already been imported from initial overseas epidemics".

And so it concludes that: "There is, therefore, no scientific rationale to support the notion that such a pandemic in the UK could successfully be 'contained' by currently-available interventions".

"This", it says, "would be especially true where the severity of infection was mild, such that many infected people did not seek care and, if found by contact tracing, did not meet the case definition for laboratory testing, so were never diagnosed and, hence, never treated, nor their contacts traced".

Thus do we see the scene set for current policy, with the document stating: "once a pandemic is present in the UK and depending on its nature, there is scientific evidence to suggest that its impact might be somewhat suppressed, or mitigated, by the judicious use of a combination of behavioural and pharmaceutical interventions".

"Depending on the impact of the pandemic", it adds, "a range of interventions are available. These vary considerably in their potential effectiveness and mode of action. Some impact on the disease by limiting spread of the virus, whilst others reduce the severity of clinical symptoms".

While conceding that much of the evidence on which the policy relies "is still characterised by uncertainty and extensive gaps in our knowledge", it then sets out a "diverse range of measures", which it refers to collectively as "defence-in-depth", but which I have already called: a recipe for failure.

We then see a twelve-point plan set out, the contents of which are, from recent experience, recognisable and eerily familiar.

Right up front it includes: "effective communication to the public, including skills training, to promote habits of stringent respiratory etiquette and hand hygiene, particularly amongst children", which explains the prime minister's enthusiasm for singing "Happy Birthday" (twice) while washing his hands in a somewhat forlorn attempt to ward off infection.

This was reinforced by "environmental restructuring" to "consolidate habits of stringent respiratory hand hygiene via cues, prompts and improved access to respiratory and hand hygiene facilities, such as tissues and soap", locking in that almost obsessive concern for hand washing, together with "increased cleaning of solid surfaces potentially contaminated with virus, such as door handles or light switches".

The plan also included "prophylactic use of antiviral drugs, especially in the earliest stages of the outbreak" and "widespread treatment using antiviral drugs, in combination with behavioural and communication interventions to encourage pharmaceutical uptake", two measures which, sadly, have proved ineffective with this particular version of coronavirus, even when augmented by "widespread antibiotic treatment of secondary bacterial infections".

Here also one also sees the reliance on awaiting the cavalry, as the document looks for "pre-pandemic vaccination, should an appropriate vaccine exist as the pandemic commences", and "pandemic-specific vaccination, initially targeted at at-risk groups, in conjunction with behavioural and communication interventions to encourage vaccine uptake".

With these measures ruled out, all we have left is "the use of facemasks and respirators to protect healthcare workers and encourage their attendance at the workplace", plus "school closures, especially when they can be instigated early in a pandemic that is severe and where transmission is disproportionately high amongst children", and "restrictions on mass gatherings, including travel, especially in the event of a severe pandemic".

Interestingly, the use of facemasks is largely considered of only marginal value, which possibly explains why there was no particular rush to issue all NHS staff with the masks.

On a technical note, here, although strictly speaking Covid-19 is not influenza, for policy and planning purposes it is treated as such, with reliance placed on the influenza pandemic preparedness work. This was certainly the case with the previous coronavirus infection involving the MERS-CoV virus. The infection was first identified in a patient in Saudi Arabia in 2012, and the disease was also called "camel flu".

What seems to have evaded planners in dealing with this current epidemic is that they would be confronted with a virus against which most established antivirals are ineffective and for which there is no immediate prospect of a vaccine.

Therefore, with no recourse to testing and isolation of cases and contacts, the only tools left in the locker – after the hand washing permutations have been exhausted - are "social distancing" and an increasingly severe lockdown.

As we see the case rate of Covid-19 increase to 41,903 (up from 38,168 the previous day), with the death toll rising by 708 to 4,313, it is all too easy to lay the blame on the current institutions and structures, but the roots of this failure go back decades and more.

We can see the roots of failure in this complacent article dating from July 1988, in which a WHO technocrat declares, on the basis of improved vaccination technology, that influenza is preventable.

Also showing up is our old friend Neil Ferguson from Imperial College London, offering his view in 2005 that a flu pandemic is "lethal yet preventable", based on his modelling of the effects of the widespread use of the antiviral Tamiflu.

We saw the BBC at the same time stressing the need for vaccines, and with the increased reliance on computer modelling well evident by 2008, the die was cast well over a decade ago for the failure we are witnessing today.

The point that so many miss is that policies to deal with major events such as pandemics take decades to develop. The genesis of the current UK policy seems to lie in the response of the Blair government in 2005 to a call by the WHO for increased preparedness for pandemics, with the production of strategy documents.

Going through several iterations, but with only minor changes, we ended up with the policy in its final form on 2014, supplemented by multiple planning documents for all levels of government – with the EU taking a close interest in developments. And, with policy essentially locked in stone, any government would have been committed to following it.

Now that Starmer has won the Labour leadership contest, he has stated that he is prepared to work with Johnson to fight Covid-19 "in the national interest".

That is perhaps just as well. The current policy belongs as much to Labour as it does the Conservatives, so it is entirely appropriate that Starmer, in between demanding that this government comes clean on the "serious mistakes" made, should own up to the mistakes made by the previous Labour administration.

Richard North 05/04/2020 link

Coronavirus: no walk in the park

Saturday 4 April 2020  

A sunny weekend is forecast, with predictions of a pleasantly warm Sunday. As we run towards the end of the second week of lockdown, therefore, the temptation to ignore health secretary Hancock's "instruction" and make the most of the good weather must be overpowering.

That tension exists over the continuation of the lockdown policy is borne out by the Telegraph, as some ministers argue for the measures to be lifted "sooner rather than later".

One minister goes so far as to argue that government would come under "increased political pressure" to lift the lockdown when parliament reopens on 21 April, and that presupposes that it has not already been confronted by a mutiny led by stir-crazy parents at their wit's end after running out of ideas to deal with bored and fractious children.

But, there are troubles lying in store for us, according to Anthony Costello (our former WHO man).

He has been speaking to a senior international epidemic expert who tells him that: "You can stop contact tracing in the hotspots, but when you lift the lockdown, everywhere at the same time, you'll face a problem: the virus will come back. New hotspots will form".

Actually, I've been thinking about this very thing, all in the context of the more general predictions about this epidemic, where modelling estimates suggested that the UK could suffer 750,000 additional deaths over the course of a pandemic, with local planners having to cope with up to 210,000 to 315,000 additional deaths over a 15 week period and perhaps half of these over three weeks at the height of the epidemic.

On reflection, if you accept that we don't have a single outbreak but many, with foci all over the country and at different stages of development, I can't see this frightening timescale being realised.

For a start, because the case and mortality totals – currently standing at 38,168 cases and 3,605 hospital recorded deaths – are largely fuelled by just a few hotspots, the population at risk to exponential phase outbreaks is not the 60 million plus of the entire nation. It could be a very much smaller figure of around ten million.

That means we're not going to see the massive figures predicted – not yet, anyway, and even then not at the speed predicted. The hotspots, as long as the lockdown is maintained, will eventually burn out as the virus is robbed of fresh meat, rather in the manner of a wildfire which has been contained by firebreaks.

The "firebreak" equivalent is the lockdown, which has put a lid on much of the spread. Thus, the opportunity for infection to pass from the London hotspot to, say, York, is fairly limited. But once the lockdown is lifted - as it must be in the not too distant future - movement throughout the country will be resumed. New outbreaks will crop up and existing small-scale incidents will be refreshed.

If we have started to see a downturn in the rate of new cases, which the CMO predicts might happen within two to three weeks, it will not last. We will be looking at a newly-invigorated epidemic and we'll be back where we started.

Costello's man thus argues that, to stop the epidemic, we must have a community programme for case detection and contact tracing. Otherwise, he says, "you won’t find the virus until it's too late".

Enter, at this point, Richard Vize, who complains that local authority activities to tackle the epidemic are being hampered by "central micromanagement". Ministers, he says, persist in the fantasy that everything works best when it is run from the centre.

The tensions aren't about money, he adds, but about communication and coordination. There have been delays, confusion and aborted work, such as changes of policy about where central and local government responsibilities lie, while public health directors are frustrated at being excluded from key communications and the development of guidance by NHS England and government departments.

As the message is that much more should be done by local authorities, the timing of a letter from Steve Battersby, Vice-president of the Chartered Institute of Environmental Health, couldn't be better.

Despite the years of austerity, he writes, there are resources in local government that we have also failed to use. There have been environmental health officers (EHOs) up and down the country desperate to help their public health colleagues – for example, with tracing contacts after testing (if there had been any).

They would also have been more effective at getting messages out to the public, particularly those most vulnerable or living in multi-occupied houses. Many EHOs have been left twiddling their thumbs for too long when their whole reason to exist is to protect public health.

You read it here first, of course. And another interesting, if familiar view comes from Michael Waterson at Warwick University. He says that it is a common view that the British government moved too late to institute a policy of testing everyone who has had recent contact with known coronavirus cases.

However, he tells us, there are several English local authorities in which there are fewer than five known cases and case density in the local population is very low. Using the most recent current figures, these include Hull, Blackburn, Stoke-on-Trent, Telford, Gateshead, Middlesbrough, Redcar and Darlington.

Testing all those who have had contact with the known cases in these areas should be a strictly limited task. Once done, subject to movement restrictions in and out, productive activity in these areas can commence or recommence, engineering facilities put to use in producing items in critically short supply – and they can once again, after many years, become an engine of growth.

With that low incidence, the monitoring of cases is easily manageable, especially if known and under-used resources such as EHOs were used, which begs the question as to why the government did not embark on an extensive community testing programme, tracing and testing cases and contacts.

Typically, the media has turned the lack of testing into a political scandal, and the fringe media is luxuriating in ever-more lurid conspiracy theories, but I'm afraid we will have to be content with that reliable old workhorse for an explanation – government (and professional) incompetence.

So far, I have managed to review government pandemic planning documents going back to 2005, such as this and this, both under Labour health secretaries, respectively John Reid and Patricia Hewitt.

Then we had this interesting document in 2006 – still under Labour's Patricia Hewitt – which gave advice to businesses, retailing the "key planning assumption" that, "during a flu pandemic, the government's overall aim will be to encourage people to carry on as normal, as far as possible". When 15 years later, we say the Johnson administration initially attempt the same policy, few would have thought that he shared it with the Blair government.

And since then, we have had an international strategy and a national framework in 2007, framed under Gordon Brown, together with an analysis of the science base for an overarching government strategy, which spanned Blair's and Brown's tenures in office.

This then brings us to the 2011 Preparedness Strategy, brought into being under Cameron's coalition government, as was the 2014 response plan and strategic framework.

A common thread running through all these plans was the limited use of community testing. It is limited to monitoring the first stage of the epidemic to establish when community spread had occurred. There is no provision in any of the plans for an extensive "trace and test" programme. In all cases the government relies for the resolution of the epidemic on the development of a vaccine, using the hospital services to hold down the death rate (mitigation) until it comes available.

In other words, while many different governments have had an input into planning the pandemic response, the short straw has gone to the Johnson administration, which has found that standing back and allowing the casualties to mount - the "bring out your dead" policy, while awaiting the cavalry is not politically tenable.

Desperately trying to deflect the political flak from their favoured son, we have serial latter day experts like Jeremy Warner and the ever-pompous Charles Moore blaming the bureaucrats, but the fact is that we are suffering from decades of inadequate policy-making.

And sadly for Johnson and his fellow ministers, they are finding that changing policy on the hoof is no walk in the park - which perhaps explains why Hancock is so keen to deprive us of that pleasure this weekend.

Richard North 04/04/2020 link

Coronavirus: strategic failure

Friday 3 April 2020  

In a breathless "exclusive", the Telegraph can "disclose" that public health officials in charge of defending the country from a major pandemic never drew up plans for mass community testing.

All this is "revealed" by Prof Graham Medley, Chairman of the Scientific Pandemic Influenza Group, who says that emergency planners "did not discuss" the need for community testing.

This is confirmed by "senior Whitehall officials" who say that the need for mass testing "did not figure in our thinking" when drawing up plans to protect the country, even though a new strain of flu-like disease has long been recognised as "one of the biggest biological threats of our time", with even the 2011 plan failing to provide for mass testing.

You really have to admire the chutzpah of these drama queens in the newspaper, though, coming up with what amounts to statements of the bleeding obvious, days after I "revealed" much the same thing, through the simple expedient of reading the official, published plan for dealing with a pandemic.

The newspaper's "revelation" thus illustrates a general inability of the media to discover things for themselves, needing a "person of prestige" to tell them what is going on before they deign to "discover" the information. And it characterises the usual arrogance of the legacy media in asserting that nothing is news until they have published it, despite the fact that this blog got there two days earlier.

However, thanks to the laborious efforts of the Telegraph, a wider, spoon-fed audience is now aware that government planners failed to make any provision for mass testing in a pandemic, which explains why we are where we are today.

As I said yesterday, it is very difficult to set up a mass testing programme, de novo, in the middle of an epidemic. This is rather like trying to redesign the engine of an F.1 car while it is racing round the circuit.

Had things been different, the implementation of a large scale testing programme would not have been that difficult, as there are more than sufficient resources. But it would have required planning well in advance, to make sure the laboratories were primed and organised, the personnel were available and the administration was in place.

The actual mechanics of taking the tests would also have to be organised, together with systems for rapid allocation to the testing laboratories (to ensure the smooth flow of work), and the processing, reporting and distribution of results.

In its rush to tell us how clever it has been, however, the Telegraph has fallen into the trap of accepting that the lack of a testing programme arose from "a lack of investment", not realising that the actual costs of setting up a programme were minimal. The major burden comes when you implement it, when, as we see now, cost is no object.

Thus, the real reason why planners did not provide for an emergency testing programme is because they didn't see the relevance; there was no intention of seeking to control the emerging epidemic. Instead, the plan was to take the hit, mitigating the effects as far as possible with heroic medical intervention, and by making plans to bury the dead on a massive scale.

Even then, there doesn't seem in the Telegraph to be any real understanding of what a testing programme is for. We have the egregious Prof Medley tell us that "Testing can be extremely powerful … at a population level to be able to understand what's going on", but this is a typical academic view of what is in fact a real practical need.

By reacting quickly to reports of illness, suspected cases can be tested and isolated, contacts identified, tracked down, isolated and tested. With efficient and fast testing in place, those suspected cases and contacts who show up as negative can be quickly released from isolation if appropriate, and positive cases can be re-tested at intervals and released once clear.

But this would suppose that the organisation was in place to ramp up contact tracing, and since no provision has been made for this, ramping up the testing capability is of less value than it might otherwise be. For sure, people can be returned back to work earlier, but there is little contribution to the control of the epidemic.

And here, there is the third lacuna, which has hardly been recognised – the insistence of the UK authorities of treating this epidemic as a single outbreak. Yet, even in the London epicentre of the UK epidemic there are obvious variations between districts. Lambeth, for instance, reports 516 cases, while Havering claims a mere 142.

There are, in fact, 32 London boroughs (33 if you include the City of London), each with populations roughly the same as Iceland. And, by treating each borough as its own epidemiological centre, the figures would remain manageable. But, in the hands of Public Health England, the whole city is served by a single office, whence the epidemic is unmanageable.

As to other areas in the country, we see a similar pattern. The People's Republic of Sheffield reports 602 cases, while the East Riding of Yorkshire – which includes the city of Kingston on Hull (situated some 60 miles east of England) can only manage a mere 56 cases. Clearly, there are multiple outbreaks in England alone and with 342 local councils outbreak management at that level, backed by efficient laboratory facilities, is a realistic proposition.

Even in Italy, we are seeing much the same thing, where the major hotspot is in the northern part of the country, with some other breakout areas further south, but with other provinces at containable levels.

Thus to have the focus now almost exclusively on the deficiencies in the testing programme, with Matt Hancock emerging from his self-isolation to promise zillions more tests – rather in the manner of Soviet despots announcing tractor production figures - is rather to miss the point.

Hancock, it seems, can dimly perceive that more testing could be A Good Thing – especially at a political level - but, like his supposedly expert advisors, only has a very vague idea of what the testing is for. As to the other defects in the management of the epidemic, these are getting hardly any attention at all.

Nevertheless, this has given Richard Horton of Lancet fame a renewed platform. Having had a "good" epidemic so far, Horton pronounces that Hancock now agrees that the UK entered this pandemic unprepared. "We did not have the scale", for testing, the secretary says so: "We have had to build from a lower base".

With that, Horton gets a fabulous "money quote", roundly declaring that, "This is a huge admission of strategic failure" – delivered just in time to make the evening headlines of all the major newspapers.

As it stands, though, the tractor production plan amounts to a promise of 25,000 PCR tests provided by the NHS and Public Health England - up from 10,000 daily tests now. But these, plus an unspecified number produced by new private sector partners, will only be delivered at that rate by the end of April.

With the current case level recorded at 33,718, with a cumulative total of 2,921 deaths, increased on the previous day by, respectively, 4,344 cases and 569 deaths, this hardly seems enough. By the end of April, at the current rate of increase, we could be seeing a daily case rate of 60,000.

By then, of course, we expect to be seeing the effects of the lockdown, so even from next week, the figures will be anxiously scrutinised for signs of levelling off and then a downturn.

If that is taken as cue to relax the lockdown, though – bolstered perhaps by "immunity passports" relying on as-yet unproven antibody tests – what's left of an already overstressed system could unravel completely.

By failing to recognise that we are dealing with multiple, distinct outbreaks at different stages of development, the easing of restrictions could lead to the spread of infection into hitherto lightly affected areas, which could then exhibit exponential increases in case rates, returning us to crisis levels.

Basically, this isn't going to be over until the government decides to change tack completely and start controlling this epidemic, instead of playing at "flattening the curve". Without that, we're looking down the long end of 18 months before a vaccine starts to be available, and another six months after that before it is available in sufficient quantity.

In two years' time, though, we could be looking at a world changed beyond all recognition. Coronavirus could even be the least of our problems, with the EU for once sharing the pain.

Richard North 03/04/2020 link

Coronavirus: death management

Thursday 2 April 2020  

The Covid-19 epidemic continues to break new records, with 29,474 reported tested positive for coronavirus yesterday (up 4,324 on the day) with 563 dead, bringing the total to 2,352, an increase of 31 percent on the previous day's figures.

There is definitely a sense of urgency in the air now, as the scale of this epidemic begins to hit home and the Mail reports the building of  another new morgue – this one about the size of two football pitches in East London, capable of holding the bodies of thousands of Covid-19 victims (pictured).

This is perhaps just as well as, by Sunday, we expect deaths to be up 1,000 a day, while the nation will be scanning the daily figures for early signs of a downturn in the case rate, indicating that the lockdown and other measures are beginning to take effect.

But yesterday was the day that much of the media decided to focus on the perceived inadequacies of the testing regime, with even the previously loyal Telegraph telling us that there is understood to be "frustration" within government over Public Health England, which is responsible for testing and is not thought to be rising to the challenge.

With dozens of expert and not so expert analyses to choose from, newspapers can be in no doubt as to where the attention lies but this is a media that never really got to grips with the technicalities of Brexit. And now, we're experiencing the same lack of grip.

For sure, testing is vitally important and, to that extent, the calls for more testing – and especially of NHS staff seeking clearance to go back to work – make absolute sense. But what is being neglected is that, in terms of controlling the epidemic, the testing is only one part of the equation.

The full package, of course, requires following up every suspect case, which – as a notifiable disease, must be reported to the authorities by GPs – testing them to see if they are positive and keeping them isolated until cleared. Then, as many contacts as possible must be traced and tested, and again isolated until cleared.

And, as we have reported so many times, even if there was the capacity to deal with all the tests, there simply are not the trained and experienced personnel within the Public Health England field epidemiology service, to carry out all the necessary visits and administer the tests.

Expanding the capability is not as easy as it sounds as there is no administrative or managerial infrastructure to handle a sudden influx of additional staff. And, as anyone who has been at the sharp end of an outbreak, administration is everything. If that is not up to the task and breaks down, as it can so easily do under pressure, then the system cannot deliver.

As to ramping up the testing, the Mail makes unfavourable comparisons between the UK's "disgraceful" performance and the "efficient Teutonic planning" of the Germans, and their "ruthless determination to work together".

But while it is easy to rail at the "staggering incompetence" of what the Mail calls "our public health fatcats", things really are not that straightforward. The implementation of a large scale testing programme is really not that difficult, as long as it is planned well in advance, and there are more than sufficient resources. An emergency programme could easily have been arranged.

At the heart of the problem, therefore, is neither a lack of capacity nor capability. The real reason for the failure to mount an extensive programme lies in the document I introduced yesterday setting out the "Pandemic Influenza Strategic Framework".

Close scrutiny of this shows that there was no provision made for mass testing. The testing was to be deployed in the initial stages only to provide early estimates of the likely severity and impact on the UK of the epidemic, and then to provide data in an "attempt to model the course of the pandemic".

When one then looks at the "planning assumptions" it is easy to see why this stance is taken. From the very start, the planners concede defeat, stating that stopping "the spread or introduction of the pandemic virus into the UK is unlikely to be a feasible option".

They then work on the basis that, once the virus is established in the UK, sporadic cases and clusters will be occurring across the country in 1-2 weeks and about 50 percent of the population may be affected in some way or another. Chillingly, they also suggest that up to 50 percent of [NHS] staff may be affected over the period of the pandemic, "either directly by the illness or by caring responsibilities".

What is not spelt out though are the necessary consequences of this stance. For these, one has to go to the guidance site for local planners, to whom is passed the gruesome work of dealing with the casualties.

Under the heading "Management of deaths", we are told that scientific modelling estimates that the UK could experience up to 750,000 additional deaths over the course of a pandemic. These figures, the guidance adds, might be expected to be reduced by the impact of countermeasures, but the effectiveness of such mitigation is not certain.

Thus, we learn that local planners "have been set the target" of preparing to extend capacity on a precautionary but reasonably practicable basis, and aim to cope with a population mortality rate of up to 210,000 to 315,000 additional deaths. As to timescale, these deaths may possibly occur "over as little as a 15 week period and perhaps half of these over three weeks at the height of the outbreak".

I am minded of that epic scene in the film Independence Day, where the President of the United States is brought face-to-face with one of the invading aliens, whence the President asks of it, "what do you want us to do?" The alien replies with brutal finality: "Die!"

That, it seems, was our role in this epidemic. Originally, no serious plans were made to control it and, while some mitigation was anticipated, the main practical response was to plan for the mass disposal of bodies. This was not outbreak management – it was the strategy of defeat.

We even have a carefully-drafted 59-page document setting out "a framework for planners preparing to manage deaths, which is only thirty pages shorter than the entire Pandemic Influenza Response Plan.

Clearly though, there has been a change in direction. Once the media, the public and the politicians got wind of the general direction of the plan, dressed up in the language of "herd immunity", the government was forced into a U-turn which required the implementation of control measures not mentioned in the original plan.

Unsurprisingly, though, it is very difficult to set up a mass testing programme, de novo in the middle of an epidemic. This is rather like trying to redesign the engine of an F.1 car while it is racing round the circuit. And therein lies the root of the "frustration" within government over Public Health England. The organisation is being asked to do something that is almost impossible.

And nor can this be put down simply to underfunding, as some are trying to do. Rather, we must look back to 2014, when the current influenza plan was published.

I do not recall then, any cries from the critics who are now so voluble in their condemnation of Public Health England – not the medical specialists, nor the opposition parties, nor the select committees, nor even the media. And now, even with so many wise after the event, they still have very little idea of what is necessary to make the system work.

Let us hope that the management of the morgues is more efficient than the management of this epidemic.

Richard North 02/04/2020 link

Coronavirus: awaiting the cavalry

Wednesday 1 April 2020  

The government needed two goes at publishing the Covid-19 figures yesterday. When they first came out, there had been 25,150 cases (up 3,009 from 22,141) and 1,651 deaths (up 367 from 1,284).

No sooner had they been absorbed, though, than the figure for deaths rose to 1,789 suggesting a truly massive hike in the day-on-day figure of over 500. But, almost in the manner of Winston Smith re-writing The Times in 1984, the day before's figures for deaths jumped to 1,408, producing a more modest but nonetheless considerable increase of 381.

To give some indication of the scale of this jump, three weeks ago, Mrs EUReferendum and I were looking forward to a visit from our granddaughter, coming down from Scotland to stay with us for a few days. Watching the daily Covid-19 figures mount, I suggested that, if the cases topped 1,000 by the weekend, we would call the visit off.

As it turned out, the figure reached 1,061 by the Saturday, at which time 21 deaths had been recorded. From that point, we went into our own personal lockdown, which was just as well.

By now we have seen cases multiply 25-fold, and while the official death toll is short of two thousand, there are those who argue that about 25 percent more people have died, putting the number at well over the two-thousand mark.

Nevertheless, according to Public Health England, the average number of deaths in England for the last five flu seasons, 2014/15 to 2018/19, was 17,000 deaths annually. This ranged from 1,692 deaths last season, 2018/19, to 28,330 deaths in 2014/15.

On the face of it, we have a long way to go before we match the 2014/15 figure, but that was particularly bad as the main strain of influenza mutated after the annual vaccine had been prepared, rendering the protection of very limited value.

However, given the current rate of increase of Covid-19 deaths, doubling every four days, the death toll for this epidemic could exceed the 2014/15 flu figure in just over two weeks, compressing the mortality into a brief six-week period, compared with the flu season which lasts four to five months, with deaths peaking over the winter months of December to February.

In terms of control, the principal difference between Covid-19 and winter flu is that the latter is constrained by an annual vaccination programme and, given an effective vaccine, the death rate can be held to relatively low levels.

Without such an aid, Covid-19 might be expected to increase exponentially, infecting up to 80 percent of the population, with a case fatality rate in the order of one percent. It was this projection, with a potential case load of 50 million that gave rise to an estimated death toll of 500,000.

What is not fully appreciated though, is that if coronavirus was left to spread freely in the population, from the current level of two thousand deaths, the half-million deaths would be reached after just nine doubling cycles – in just over five weeks' time.

That is the nature of an exponential growth rate where, in a population with no natural immunity, we would see half a million dead within the space of just over two months. There is not a health system in the world that could cope with that burden. Long before the final death toll was reached, the NHS would have collapsed.

In real life, however, epidemics don't work that way. As the numbers falling ill increase, the incidence of infection slows, with the graph taking on the profile of the classic bell-shaped curve. Nonetheless, in theory, this might extend the epidemic by a few weeks, so we could still see a grotesque number of deaths compressed into a period that would swamp the health service.

And yet, even that isn't going to happen. A very good point made by the BMJ yesterday is that, while there is one epidemic in the UK, there are multiple outbreaks, each with their own unique profiles. At the moment, the largest of these is in London, and there is another hotspot in the West Midlands.

Given unconstrained growth, we can expect the outbreaks to radiate out from London, to the west and north – rather like the Italian experience where the epicentre is moving south. Over a period therefore, we can expect a series of spikes in incidence and mortality, as the disease spreads.

This gives a longer period with which to cope with the epidemic but, without specific controls geared to this specific disease, there would be no overall impact on the number of dead. Rather, the deaths would be spread over a longer period.

You can play about with the statistics, and come up with different projections – with or without the spurious authenticity of calling them computer models – but these will have no effect on the overall dynamics of this outbreak.

Thus when confronted with a novel virus, giving rise to acute respiratory disease, in the absence of a vaccine, there are only very limited control options. The first – as favoured by the WHO – is to carry out an aggressive testing programme to detect cases, combined with equally aggressive contact tracing and testing, to remove the infection from the community.

The other main option, applicable where the community spread is uncontained, is to impose a widespread lockdown, distancing the population from the sources of infection in the hope that the epidemic will slow down sufficiently to allow the health services to deal with the onslaught of cases.

But, in fact, it now transpires that the UK government has gone for neither of those options. The clue to this came with last weekend's article which recorded the failure of a pandemic test run carried out three years ago, under the title "Exercise Cygnus".

What emerged from the article is that, even though the system failed, no amendments were made to the strategic roadmap for a future pandemic, with the last update having been carried out in 2014. The actual working model for the current Covid-19 epidemic, therefore, is the Pandemic Influenza Response Plan, augmented by the Pandemic Influenza Strategic Framework, both published by Public Health England in August 2014.

And in those pages is the previously "opaque" reason why Public Health England so precipitously abandoned the "test and trace" programme, an action which has attracted so much criticism.

The point emerges from the plan that the savagely diminished field epidemiology service was never intended to carry out this programme. Its function was merely to monitor the emerging epidemic, looking for "evidence" of sustained community transmission.

This would be undertaken during the first two phases of the plan, labelled "detection" and "assessment", following which the field service was effectively stood down, while the plan moved to the "treatment" phase, in preparation for "targeted vaccinations" – all based on the assumption that a vaccine would be available 5-6 months after the decision to order it had been given.

With that, the plan moves into the "escalation" phase, amounting to "surge management" of cases by the NHS, which includes "prioritisation and triage of service delivery with aim to maintain essential services". Also introduced are "resilience measures, encompassing robust contingency plans" and then, in the ultimate statement of complacency, Public Health England considers "de-escalation" of its response "if the situation is judged to have improved sufficiently".

This then leads to a "recovery" phase, the end point where we are supposed happily to settle down to the "normalisation of services" and "perhaps to a new definition of what constitutes normal service". And with that, we get "restoration of business as usual services", including "an element of catching-up with activity that may have been scaled-down as part of the pandemic response".

Such a happy outcome is, however, entirely dependent on the development and administration of an effective vaccine, without which there is neither hope nor intention of controlling the epidemic. Stuck as we are in the "escalation" phase, the plan is to hold the fort long enough for the cavalry to come galloping over the hill.

And, seriously, that is what the government is doing.

Richard North 01/04/2020 link

Coronavirus: addressing the issues

Tuesday 31 March 2020  

I wonder if Peter Hitchens and his supporters would dismiss this as a fantasy got up by the Daily Mail, or claim that it represents just a typical week in the life of an NHS doctor.

But then, we could simply accept that the 22,141 reported cases of Covid-19 are nothing different than one might expect from a normal winter flu outbreak, in which case the "lockdown" policy is indeed "grotesque, absurd and very dangerous".

As for the 1,408 dead, they are apparently just a reporting artefact arising from the failure of doctors to understand reporting guidelines, thus mistakenly pronouncing Covid-19 as the underlying cause of death when it should merely have been noted as a contributory cause.

We must also believe that physicians throughout the world – even in relatively sophisticated regimes such as that prevailing in Northern Italy – are repeatedly failing to conform with the WHO recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD), and the standard coding for Covid-19.

It must also be accepted that the medical profession is routinely ignoring the long-established WHO Instructions on recording causes of death, even though they have been in place since 1979.

Thus, having discounted so many erroneous reports, and completely ignored multiple suggestions that the true death rate is being substantially under-reported, we can rest easily in our beds in the knowledge that Peter Hitchens is the one true voice of sanity.

Clearly, we must regard this epidemic as nothing more than a minor perturbation. The disruption and costs of taking action quite obviously outweigh the minor inconvenience of geriatrics dying earlier than they might otherwise have done, especially those who have died with coronavirus and not of it, after all those doctors have bungled the certification.

On the other hand, it might just be possible that what we are seeing is a real epidemic of a dangerous disease which has caught out most of the nations in the world, including the United Kingdom which is showing itself to be demonstrably unprepared for dealing with a crisis of this nature.

If this seems to be a more plausible interpretation of current events, then we can forego the wisdom of Mr Hitchens and devote ourselves to an analysis of what went wrong, and what must be done to fix it.

That other countries might have been similarly unprepared is of no real comfort to us here in the UK. Each country has its own system and its crosses to bear, and what applies to other countries might not necessarily have any relevance to our situation.

However, it is germane to note that it isn't only the Lancet that is raising a hue and cry over the government's failures. The British Medical Journal has joined in, with a long editorial declaring that: "Testing and tracing must resume urgently".

On 24 February, it says, there were nine confirmed cases of Covid-19 in the UK. On the same day, the World Health Organization recommended countries outside China with imported cases or outbreaks "prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts".

On 22 March - when there were 5,683 confirmed UK cases - Michael Ryan, executive director of the WHO health emergencies programme, repeated the message on the BBC: "What we really need to focus on is finding those who are sick, those who have the virus, and isolate them, find their contacts and isolate them".

Says the BMJ, echoing exactly the message I have repeatedly published on this blog: "This is entirely unexceptional. Case finding, contact tracing and testing, and strict quarantine are the classic tools in public health to control infectious diseases".

This really cannot be emphasised enough or repeated too many times. We are not talking about some arcane or disputed procedure, but the very basic nuts and bolts of outbreak management.

The WHO, we are told by the BMJ, says the recommendations "have been painstakingly adopted in China, with a high percentage of identified close contacts completing medical observation". In Singapore, Vietnam, and South Korea meticulous contact tracing combined with clinical observation plus testing were vital in containing the disease.

This combined with strong measures to enforce isolation for travellers returning from high incidence areas obviated the need for a national lockdown and closure of all schools in Taiwan and Singapore.

Furthermore, the mathematical model used by the UK government clearly shows that rigorous contact tracing and case finding is effective: the prediction of 250,000 deaths was predicated on what would happen without contact tracing.

Despite this, contact tracing started in the UK but stopped early in the epidemic. How effective it was is questionable, especially in England and Wales, which made Covid-19 a notifiable disease only on 5 March, two weeks after Scotland and a week after Northern Ireland. This, coupled with the lack of surveillance and testing of those contacting primary care, says the BMJ, suggests the number of confirmed cases is an underestimate.

It then declares that the reasons why tracing was stopped, against WHO recommendations, have not been published. They seem, it says, "to be connected to a shift from 'contain' to 'delay' in the government’s action plan, when contact tracing was replaced rather than supplemented with other control measures".

One reason, it advances, seems to be a lack of tests and testing facilities. However, it says, testing is a support not a substitute for tracing or medical observation, which is crucial.

Current tests for the virus require careful validation and have low sensitivity, resulting in many false negative results, especially in the pre-symptomatic phase when viral load is low. As many as 40-50 percent of patients tested negative initially in China, and so the definition of confirmed cases was changed to include those with clinical symptoms.

But it then goes on to say that another factor is the decision to treat the situation as a single national epidemic rather than scores of local outbreaks each at different stages, needing to be tackled locally.

National figures conceal huge variation in confirmed cases, ranging from over 400 in Birmingham and Hampshire to fewer than 20 in Blackpool, Hartlepool, Darlington, and Rutland. In Scotland the first case was identified on 1 March, and Orkney and the Western Isles still have no cases.

In the much less severe H1N1 flu pandemic in 2009, this same approach "seriously impaired the ability of local agencies to respond in a flexible, timely and pragmatic way to the rapidly emerging situation".

Matters have worsened since 2009. Central control in England was entrenched by the 2012 Health and Social Care Act, which created Public Health England (PHE) to protect the health of the public in England and gave local authorities the duty to improve the health of their local populations.

PHE is legally in charge of communicable disease control and sits outside the NHS and local government in its regional hubs and field epidemiological services. Directors of public health in local authorities have little scope for proactively taking local control.

These changes are exacerbated by the decimation of public health and laboratory facilities for testing. The decrease in numbers of consultants in communicable disease control and community control teams, together with swingeing local authority cuts since 2010, have reduced the chances of a strong local response.

Local pathology and virology services have been centralised and partly privatised, leading to a fragmented mix of for-profit and public laboratories and serious staff shortages.

The scientific evidence has been dominated by behavioural science and mathematical modelling, with communicable disease control and public health sidelined. This leads to a lack of scientific challenge, as in the 2009 flu epidemic.

This very much tallies with the comments of Gabriel Scally, a former regional director of public health. He reinforces the theme of this blog that the public health service in England and Wales has been seriously depleted.

The result, he says, is the absence of any integrational, coordinating or management function at a regional level in England that could operate between Whitehall departments and the various bodies, often very local, that are charged with implementing government policy.

But it goes further than that, a situation to which Pete alludes, where the fundamental structures of government have been forgotten. This is the "invisible government" which I discussed back in 2008, the vital systems that keep society functioning, mostly without people realising they exist.

Predictably, the BMJ is urging that WHO's mantra of "trace, test, and treat" must be followed. It is not too late, it says, to adopt WHO Guidance. A second and third wave of the epidemic is likely. Contact tracing must recommence.

This, it says, means immediately instituting a massive, centrally coordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the manuals and guidance published by China.

Sadly, it ain't that simple. Having done the job in the field, I can attest that contact tracing is not an easy job. It requires training, skill and experience – and local knowledge, which can shave hours off the process of actually finding people.

This is a job that could and should be done by local authority environmental health departments which, if pushed, could put 10,000 trained professionals into the field. It is a measure of how far the system has deteriorated that these departments were not engaged from the very first.

Sadly, the BMJ concludes that the structure and capacity of our depleted healthcare system is now largely driving the response to this epidemic. It will, it says, continue to do so until services that support local communicable disease control are rebuilt and reintegrated.

And that is the truth. The blue light brigade may have the glamour and the happy-clappy support of the nation, but attention to the routine nuts and bolts of public health could have made all the difference.

Richard North 31/03/2020 link

Coronavirus: apportioning blame

Monday 30 March 2020  

Chris Hopson, chief executive of NHS providers, is not happy with the criticism meted out by the Lancet over the handling of the Covid-19 epidemic. In his view, "We need to ignore the siren voices seeking to divert attention from the task at hand. The time for debate about what could have been done better and why is for later, not now".

In this, Hopson has the support of David Nabarro, described as "a special envoy of the WHO director general". He says that this is not the time for blame, arguing that we need to get ahead of the pandemic. In this rapidly evolving situation, he adds, we must think ahead and react fast. It is far too early to judge what has worked and what has not.

That plea, however, is less impressive when one learns that Nabarro has his feet under the table at Imperial College, London, home of the Covid modellers whose dark arts have done so much to shape the government's response to this epidemic.

Yet, as the epidemic reaches 19,522 cases and 1,228 dead, there is by no means a consensus about shelving any criticism for the time being. Former Defra chief scientific advisor, Ian Boyd, observes that, "The middle of a crisis may not be the best time to suggest why we should learn lessons". But, he says, "many people are more likely to listen now. Certainly, nothing should distract us from getting ahead of Covid-19. My concern is that we should come out of this much wiser".

He is not wrong there. Although Michael Gove asserts that, "once this dreadful epidemic is over there will be an opportunity for all of us to look back and to learn appropriate lessons in order to make sure that our public health system is as resilient as possible", there are endless examples of government inquiries, ranging from BSE to Foot & Mouth, turning out to be useless whitewashes.

Certainly, in addition to this blog, there are others who are not holding back their criticism, not least Peter Hitchens. However, rather than tackling the inadequacy of the government's actions, Hitchens is one of those who is calling into question the whole basis of the crisis, joining what might be called the "Hannan tendency" (pictured).

Referring to the response to the epidemic as the "Great Panic", Hitchens seems to rely on the views of Sucharit Bhakdi, a Germany-based medical microbiologist, who dismisses what he calls the "extreme preventive measures" as "grotesque, absurd and very dangerous".

Strangely, this man – while recognising the epidemic in Italy - attributes the high death rate to "exceptional external factors" such as air pollution, compounded by the multi-generational nature of many Italian families. He thus posits that "scenarios like those in Italy or Spain" are not "realistic" in Germany – an exception which Hitchens takes to apply to the UK.

Hitchens is anxious to talk up the credentials, referring to the professor "as one of the most highly cited medical research scientists in Germany", who was "head of the Institute for Medical Microbiology at the Johannes Gutenberg University of Mainz, one of Germany's most distinguished seats of learning".

This is a classic resort to prestige, amounting to an appeal to authority, but one should note that Bhakdi has no record of any work in the field of epidemiology, and it is very much the case that "medical microbiology" is not a qualification in that very different field.

A balanced view might take account of the doubts about Bhakdi's assertions but, armed with his "expert" Hitchens evidently feels equipped to challenge the entire global medical and scientific establishment.

I have a lot of time for Hitchens and recognise his position, having been there with Salmonella and eggs, the non-existent listeria epidemic, and the furore over BSE. When it comes to the projected figures for UK deaths in this epidemic, it is easy to make the case that some of the estimates are overblown.

Even the famous Foot & Mouth modeller, Neil Ferguson, who recently warned that around 510,000 people in Britain would die if no action was taken to control Covid-19, also predicted that up to 150,000 people could die from CJD transmitted from cattle. To date there have been fewer than 200 deaths and vCJD has all but disappeared.

Nevertheless, I am strongly inclined to the view that the Covid-19 epidemic is real, and serious – even if the peak illness and the mortality rates for the UK are as yet unknown.

On the basis of the facts known about this newly emergent disease and its increasing incidence in the UK, no responsible government could have refused to take action, bearing in mind that epidemics are public events and the response is as much political as it is medical.

If there are valid criticisms to be made – and I believe there are – I would put three specific issues at the top of the agenda.

The first is the deterioration of the epidemiological field service in the UK, which has clearly meant that the early stage "test and trace" response was abandoned – almost certainly prematurely. Richard Horton may be voluble about the failure to act over that last few months, but here we are looking at structural issues which go back decades.

Secondly, one must question the lack of preparedness, even though it was known, after an exercise in October 2016, that the capacity to deal with a major epidemic was wholly inadequate.

Thirdly, I would question the reliance of the NHS on its established "surge" programme, expanding capacity in existing hospitals to deal with the illness generated by the epidemic.

In a situation where the service is dealing with a highly infectious viral disease, for which there is no cure and for which there is no vaccine, it seems to me a higher form of madness to bring affected patients into buildings already populated by the sick and vulnerable.

One could argue that the planners have succumbed to a form of arrogance, amounting to hubris, in assuming that they could manage a rampant infection within existing facilities, when our forefathers – without the benefit of modern medicines and techniques – kept infection away from the general hospitals, in fever hospitals, sanitoriums and the like.

Here, one must also express concern that the conversion of the NHS into a National Covid-19 Service, abandoning patients with other conditions, is not the wisest use of resources.

It is a pity, therefore, that Hitchens (and many of like mind) have launched off in what appears to be the wrong direction, when there are serious issues to confront and where, in the fullness of time, blame must be apportioned. The failures should not be treated solely as "learning opportunities" from which those responsible can walk away with promotions and higher salaries.

Richard Horton argues that something has gone badly wrong in the way the UK has handled Covid-19. Somehow, he says, there was a collective failure among politicians and perhaps even government experts to recognise the signals that Chinese and Italian scientists were sending.

We had, he says, the opportunity and the time to learn from the experience of other countries. For reasons that are not entirely clear, the UK missed those signals. We missed those opportunities and, in due time, there must be a reckoning.

But here, I am with Ian Boyd. Unless the issues are identified in the here and now, and kept alive in the public consciousness, when it comes to the ex post facto evaluations, inconvenient facts will be quietly buried and forgotten.

And even if it turns out that the response to Covid-19 has been overblown and we weather this epidemic, like the proverbial No.9 bus, there is always another one behind. We are paying for this epidemic in blood and treasure. As well as sanctioning the guilty, it would be a tragedy if we did not learn the lessons it gives us.

Richard North 30/03/2020 link

Coronavirus: uncertainty and confusion

Sunday 29 March 2020  

You don't have to be a genius - or even the "brilliant" Neil Ferguson, whose computer modelling is taking a bit of stick - to work out where we could be going with Covid-19 epidemic.

Yesterday's burden of reported cases stands at 17,089 and if we make the conservative assumption that the numbers will double every five days, then by the end of the next fortnight we will be looking at 85,000 cases – not far short of the 92,472 being reported in Italy.

As for deaths, with 1019 reported yesterday (those who died in hospital) we could be looking at between 8-10,000 by the end of the fortnight, not far short of the 10,023 currently being reported in Italy, even if there is no guarantees that that figure is accurate, when local mayors suggest that the true death rate could be four times that posted.

In fact, we're not going to get accurate figures for a while yet – if at all – and we may have to rely on year-on-year comparisons, looking for a spike this year when compared with last year's figures – with adjustments which will keep the academics arguing for decades to come.

But, if we take the current Italian figures as a rough marker - against which to measure the UK performance in containing the epidemic – then if in a fortnight's time we weigh in with smaller numbers then we might take this as small sign that that the "lockdown", imposed last Monday, is beginning to have an effect.

Even then, the figures – as always – will need to be interpreted with care. We tend to use the words "epidemic" and "outbreak" interchangeably, but they are not actually the same. Technically, an epidemic is an incidence of communicable disease in excess of expectations so, in theory, since Covid-19 is a new illness and the expectation was zero, even one case could be regarded as an epidemic.

An outbreak, on the other hand, is two or more cases linked to a common source. This means that, as the epidemic has progressed, multiple sources have given rise to many different foci of infection, each becoming outbreaks in their own right.

Thus while we have one epidemic, we now have multiple outbreaks, each at a separate stage of development. The London outbreaks (probably in the plural) seem to be most advanced, which means that they will peak earliest and begin to decline.

By that time, however, we could be experiencing a ripple effect: as cases in some areas are on the decline, others might be increasing. And, as those in turn peak and start to decline, other areas may be experiencing rapid increases.

Thus, crude national figures may not give an accurate (or any indication) as to the effect of controls in specific areas (successes or failures), and it is only when we see a sustained downturn that we'll be able to say that the disease is in check – for the moment.

That, however, does not stop us experiencing a resurgence of the disease later on, and we could perhaps see a cyclical incidence, especially if acquired immunity is short-lived and/or the virus mutates, whence we could see a repeat performance of the last few months. And that state could continue until a vaccination is available in sufficient quantities to launch a national vaccination programme.

In the meantime, all we have to look forward to is uncertainty – and much confusion. For instance, on the one hand, we have Tom Pike of the Imperial College, London, playing with his models to tell us that the UK might get away with the surprisingly precise figure of just 5,700 deaths, on the assumption that social distancing will keep the daily toll of deaths below 250.

Given that yesterday's total was 260 deaths, and today's figure will almost certainly be higher – as we are recording the demise of people who may have acquired their infections more than two weeks ago – the chances are that we will be seeing steady daily increase for at least the next week, and high levels beyond that.

Clearly, Stephen Powis, the medical director of NHS England (pictured), hasn't got the memo. Answering questions via a video link during a coronavirus media briefing at Downing Street yesterday, he ventured the opinion (initially advanced by Imperial College) that, "If we can keep deaths below 20,000 we will have done very well in this epidemic".

Powis is confident that, if the overall figure is held below that level, we can stay within the NHS capacity, which is probably a reasonable assumption given that, in addition to the three emergency treatment centres being planned (in London, Birmingham and Manchester), one is being considered for Cardiff and, in all, some 13 venues around the UK may be used to give emergency treatment.

It is debatable, however, whether these centres will have as much effect as hoped. Reports indicate that, to date, patients in UK intensive care only have a 50 percent survival rate.

In the new centres, there will undoubtedly be a dilution in the standards of care – this much is anticipated – in which case the survival rate might be even lower. This is leading to suggestions that much of the effort being expended will be wasted. "The truth is", one doctor says, "that quite a lot of these individuals [in critical care] are going to die anyway and there is a fear that we are just ventilating them for the sake of it, for the sake of doing something for them".

This rather puts into perspective the comments of deputy chief medical officer who declared that, although WHO recommends testing (and tracing), it is advising all countries including low and middle income countries. But, for Britain, this is "not appropriate". She says:
We have an extremely well-developed public health system in this country … when you come to the UK, we have made it very, very clear that there has been a plan right the way through this which is entirely consistent with the science and epidemiology. We started with a containment phase and every early case of this disease was followed through, every contact was traced exactly as we would do for other diseases … but there comes a point in a pandemic where that is not an appropriate intervention and that is the point really where we moved into delay and, although we still do do some contact tracing and testing … that is not an appropriate mechanism as we go forward. At that point, what we need to do is focus on the clinical management [of new patients].
The point is, of course, that if "clinical management" is only partially effectively, then it is hardly appropriate to rely in this. The emphasis on prevention must surely take precedence.

This, therefore, simply adds to the confusion, especially as The Lancet has condemned the government's handling of Covid-19 as "a national scandal", stating that [the] "basic principles of public health and infectious disease control were ignored, for reasons that remain opaque".

The article goes on to say that the UK "now has a new plan: suppress; shield; treat; palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come".

Nevertheless, the government is sticking to its story, with Yvonne Doyle, Medical Director, Public Health England, giving oral evidence to the Health and Social Care Committee last Thursday (26 March), claiming that, from mid to late January until the middle of March, the strategy was one of test and trace.

At a point before we stopped that intensive contact tracing, she says, "it became clear to us that there were what I call dead ends of contacts where you had a case, you tried to find the contact, and it just was not possible, because that gave us the indication that there was sustained community transmission". There was, she also said, "limited capacity in the field service to contact hundreds of thousands of people".

What she doesn't say, however, is quite how limited that "field service" actually is, with the latest Public Health England report identifying a total staff resource of 2,093 (with a budget of £86.9 million) dedicated to "protection from infectious diseases". That includes operating national centres, regional network and maintaining the capability to identify infectious disease, its surveillance and the management of outbreaks.

The report does not identify the specific number of field staff dedicated to contact tracing but, in the nine regional centres, it is probably substantially less than 1,000 – the entire front-line, national capability available to deal with this Covid-19 epidemic.

An article in Zeit has Doyle complaining that there was "a lack of staff" to deal with the epidemic, but that is not the real problem.

No government is ever going to maintain thousands of professional staff, sitting idle on the off-chance that a major epidemic will come along – any more than it will keep a vast standing army to protect us in the event of war. As with the army, we need a core service capable of expanding very rapidly to deal with emergencies as they arise. This is not a staffing problem, per se, but a structural one, and one which the government seems rather keen to conceal.

Meanwhile, Mr Foot & Mouth says the lockdown will have to last until June if we are to avoid the worst effects of the epidemic unless, of course, Ferguson repeats his brilliant wheeze and has the government slaughter all coronavirus contacts – which is what it seems to be doing anyway, albeit by default. Never mind, the "British spirit" will see us though, says Johnson – those who survive.

Richard North 29/03/2020 link

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