Category Archives: Economy

Coronavirus – blog review

I thought it worthwhile to summarise some of the points made on this blog so far with regard to the new Coronavirus.

I re-emphasise that I have no expertise in biology and medicine, but I do have some in public policy (and I happen to speak German, thus enabling the comparison between the English-speaking world and the German-speaking world upon which I intend to build in the coming days and weeks). These are analysis pieces for information and interest; they do not constitute formal research, far less government policy.

If, like me, you are in Northern Ireland, remember the core government advice currently remains stay home, save lives.

In summary, the most important thing right now is that there must always be room for doubt. We still do not understand this virus, so we cannot say anything about public policy responses with absolute confidence (so those who do are making it up).

We must be aware that in our own response to this, it is as much about managing and perceiving risk as anything else. Also, the objectives are not quite as obvious as we might at first think. Even when we establish what they are and judge performance thus far, we must also be aware that our own intuition may be deceiving us fundamentally and always apply the plausibility and relevance test.

Therefore, never has the truth been more important. Almost anything said with absolute certainty does not merit attention – it is invariably said to appeal to prejudice rather than truth. We even need to consider that the reverse of what we view to be instinctive may end up being true. There is also considerable risk in simple, apparently clear claims which are in fact profoundly misleading, even to the extent of missing key points in their favour. If we must make comparisons… well, we probably shouldn’t too often.

“Lockdown” always was a profoundly good idea, provided it was properly prepared for. However, it is a long way from the “safe” option it is sometimes presented as, and it cannot last forever. Even right now, you can legitimately argue for or against “raising lockdown”, but make sure you are asking the right question. When it is raised, however, other countries can be taken into account and it must not be done piecemeal, but rather via a phased or staged approach, and based on the Regulations which set out what we are trying to achieve.

For all the discussion about “lockdown, however (understandable because it is what most obviously affects most of us), the difference between good and bad outcomes is predominantly to do not with “lockdown” but with early diagnostics. This truth may be boring but that does not make it less true – indeed, we should always be seeking solutions, not headlines. It is also legitimate to attack the UK Governent for its early inaction, but such attacks must be specific to where it actually erred otherwise they serve no purpose.

It is also important to report what actually matters to us. Targets and personalities are meaningless; actions and delivery are what count. We should probably also define our terms. “Social distancing” does not mean “lockdown”, for example – saying the former must remain for months or years does not mean the latter must.

One of the difficulties in dramatic here-and-now news is it misses the broader analysis, such as the awkward truth that the difference in outcomes between the UK and Germany is not narrowly in the two countries’ response to the new coronavirus (regardless of the UK Government’s very evident failings in that regard), but in the fundamental basis of their health services. The UK is always fire-fighting whereas German-speaking Europe puts in the early preparation in a targeted way – this reveals itself further in the two countries’ testing strategies. Yet, for all that, things in Germany are (and were, when the linked piece was written) nothing like as smooth or simple as they are reported in the English-speaking world (and they are still not even post-lockdown); its lockdown was fundamentally less strict.

There are also differences within the UK just as there are within Germany – Northern Ireland is going its own route in some significant areas and has its own recovery plan, maintaining rightly or wrongly a later lockdown, which is not perfect but is an improvement on the UK Government’s. We have also not paid enough attention to the immense challenges of re-opening the Health Service. To some degree, this is what devolution is all about.

There are some quirks, too, such as why planes are still in the air and why we need the return of sport. There is also always the chance that we are closer to the end of this than we think – but that really is not very likely. We are probably over-thinking apps, and there are also always just random questions.

We also need to consider our own personal well-being, not least how we think our way through living during the virus and after it and how we imagine the future.

Where does all of this end? There will surely be some good to come out of it; we just do not know when.

I have also included some Facebook posts, for example on how we ourselves can balance probabilities in terms of virus transmission; the meaning of “Step 1” in Northern Ireland; on the practicalities of shopping with the virus about; and on that ever present danger of comparisons.

I also reckon this external article from Unherd is essential reading for anyone genuinely wanting to understand the public policy and scientific challenges around all of this.

In the meantime, here is some outline practical guidance primarily for people in Northern Ireland.

Coronavirus – the relevance of plausibility…

In the NDR podcast with Germany’s Chief Virologist Christian Drosten last week, presenter Korinna Hennig gave the example of a headline “Does eating strawberries help with the Coronavirus?” to which, when you read the article, the answer was clearly “no“. However, by the time you have read the article, the idea has already been planted that strawberries may help with the Coronavirus – and that is the inherent risk in the headline.

It is always useful to apply our plausibility and relevance test!

(And no, it is not “plausible” that strawberries help in any way at all – other than, perhaps, steering you away from chocolate in the interests of your general health…)

United Kingdom

Daily Mirror headline ran yesterday that “19 million” people in the UK may already have been infected.

Technically, this is just about plausible; a death rate at the very lowest conceivable based on current research would just about allow that conclusion.

However, it is so close to the borderline of plausibility as to be irrelevant and therefore frankly irresponsible, as implicitly it suggests pre-vaccine “herd immunity” is a viable means out of the current crisis, when there is minimal evidence to suggest this is true (although, under London below, it is not to be ruled out completely).

In fact, later the same day, the UK Government released evidence that in a two week period from late April to early May fewer than 150,000 people in England were infected at any time. This would push the overall number since late February very low indeed.

The balance of the evidence is that around 3-4 million people across the UK have been infected. That is very plausible.

It is, of course, not much of a headline – but therein lies the problem with too much media reporting currently, particularly in the press.

Northern Ireland

A BBC headline ran yesterday “70% more Coronavirus deaths than official figures”.

How plausible is that? And how relevant is it?

Well, of course, it is plausible. Not only do official daily counts in Northern Ireland record only those dying having tested positive for (or, latterly, having been diagnosed with) COVID-19, but they are quite openly counts of registered deaths up until that point. A combination of deaths “assumed” to be COVID-19 (which only appears on the final death certificate or theoretically may even in the end be determined by a Coroner), excess deaths on which COVID-19 had some effect (even, say, a heart attack for which the patient did not seek immediate attention), and the simple lag in reporting deaths all mean that it is plausible that the total number as of this moment is around 70% higher than the official daily count figure.

There is an issue here, however, with the relevance of the way the headline is worded. Implicit to it is the suggestion that deaths are somehow being “hidden”, even that the record is being tampered with to make it look better than it is. On the absolute contrary, Northern Ireland is one of the quickest jurisdictions in the world to publish excess death figures and thus enable a full comparison of total excess deaths, with deaths assumed to be associated with COVID-19, and with the official daily count of those diagnosed with COVID-19 before death.

A very common error here, made even by one of the “experts” providing evidence to the Health Committee at Stormont on Thursday, is to compare the “excess death” figure in the UK (the publication of the overall figure for the UK is slightly slower than for Northern Ireland alone, but still relatively quick by global standards) with the “tested positive for COVID-19 figure” for Germany (which is the only one we have beyond early April, but is clearly a lower total – by definition, we do not know by how much). This is a totally flawed comparison, and anyone defining themselves as an “expert” needs to do better.

The headline was all the more curious because it ran with figures two weeks out of date.

The figures as they were published yesterday are interesting not because of the gap between daily count and excess deaths (which we have in fact known about for weeks), but because they provide a clear argument for lockdown, at least as an initially important policy intervention. That is the relevant point here.

The question raised by a blog post a few days ago was whether the excess deaths were being caused by COVID-19 (but just missed by medical professionals) or by lockdown itself. Either was plausible, but the figures provide evidence towards the former.

None of this is perfect, because we are trying to compare deaths by date of occurrence with deaths by date of registration, and in a relatively small jurisdiction even minor statistical biases or errors can cause significantly different apparent outcomes. Nevertheless, fundamentally, if lockdown itself were causing deaths (in the immediate short term), we would expect that number (not the share, the number) of excess deaths over those attributed to COVID-19 to remain relatively stable. The evidence had suggested that it was relatively stable over a three-week period to 1 May (though we cannot yet absolutely know for reasons aforementioned) but in the week to 8 May we see an apparently dramatic decline. In the five weeks from the last week in March (i.e. to 1 May) deaths attributed to COVID-19 accounted for only 71% of all excess deaths in Northern Ireland; but in the six weeks from that week (i.e. to 8 May) that figure rises to 76%.

It would not appear to be “good news” that more deaths are being and thus potentially can be attributed directly to COVID-19 than until now, but at least it means that lockdown itself has not had quite the effect we may initially have feared in terms of people not seeking treatment in emergencies. However, that does not mean it has had zero effect; and nor does it mean at all that the long-term effects of not screening for cancer or the psychiatric difficulties inevitably associated with lack of social contact will not be considerable.

Republic of Ireland

This can work the other way, too. On Wednesday, the Republic of Ireland initially announced just 33 new cases. This seemed just about plausible, given already by this stage those were the sorts of figures emerging from the whole of London (with a much higher population), although it seemed a little unlikely (we will come back to why below).

Yet the next day, it announced 426 new cases. Questioned about this, its Chief Medical Officer said that the 426 included an “accumulation” of cases from one hospital which were being announced at once. This seems relevant, but also stretches plausibility – why would you declare 33 one day when you are sitting on hundreds?

Few journalists thought to ask the obvious question but thankfully two did. One revealed that there had been a significant problem with testing (potentially relevant to when infections are actually being determined); another revealed that of the 426, 223 were “accumulated” at one hospital but this was a problem because it was unclear if there had been any contact tracing of those 223 (definitely relevant). There is also the obvious problem that this would still leave the daily count at 203, up from 33 initially announced (but as one commenter subsequently points out, also subsequently published as 159) the previous day, which is implausible.

The problem is, this whole thing led to a debate about whether figures were being tampered with ahead of the announcement on raising lockdown from Monday. This is probably not the case, but in some ways that is more worrying – the first rule of the plausibility and relevance test is that in the battle between conspiracy and cock-up, it is almost always the latter…

London

On Thursday, according to a Cambridge University study there were just 27 new cases in London (population over 8 million). Given that it had long been suggested that in London R<0.5, this is just about plausible (although the above does make you wonder).

However, is it really plausible? The assumption was that in London R<0.5 because there had been so many cases to begin with that even relatively high figures constituted a sufficient decline on earlier numbers to deem the R-number relatively low.

This is combined with the notion of “undercover spread”, widely discussed in German-speaking Europe but completely missed in the English-speaking world.

Essentially, even under lockdown, the virus will spread into areas it has not previously touched – be that regionally (say into previously less affected parts of England like the South West) or even socially (say, into care homes); therefore even if R=1 and the virus is not spreading exponentially overall, it will almost certainly be spreading exponentially in places not previously heavily hit – essentially because the same number of infections proportionately means previously less affected areas will see R>1 while previously more affected areas will see R<1.

This is one of many problems with relying purely on R!

However, only 27 new cases is an extraordinarily low number. Certainly relevant questions need to be asked:

  • Is testing being properly carried out (there are serious questions around the quality of tests when testing is based around random targets rather than established outcomes)?
  • How are confirmed cases actually being “confirmed”?
  • Are there cases not being assigned to a particular region?

If it really is as low as that, it opens up two relevant policy options which are completely contrary to each other:

  • Is it, in fact, plausible to go for outright eradication in London (and, by extension, the whole of the UK and Ireland) by extending lockdown?
  • Or, almost completely conversely, is it plausible that this figure so low because some sort of “herd immunity” has already been built up in London, where the virus spread very quickly before lockdown (this is what Sweden has been banking on all along)?

This is where the quest for plausible figures becomes hugely relevant…

 

Coronavirus: Preparing the health system for the future

Full version of an article from earlier this week in the News Letter.

The fundamental objective of all governments in the West in tackling the coronavirus crisis is to ensure their health systems are not overwhelmed. However, this requires a balance between the understandable priority to maximise capacity for managing COVID-19 itself with the ongoing need to manage other diseases and conditions, which can themselves be life-limiting without the intervention and treatment of health professionals. The outcome in Northern Ireland and perhaps elsewhere will surely be faster transformation of Health and Social Care.

Studies in the UK reported by the BBC show the decision to suspend cancer screening for the duration of the coronavirus crisis may mean as many as 100 people in Northern Ireland each week are not being diagnosed for cancer; studies from Germany show that people are not reporting to hospital even with mild heart attacks, which are therefore going untreated. The evidence is that this alone will result in years of lost life, as treatment in either case begins later than it would otherwise.

There are also questions also about when and how the treatment of long-term conditions will be restored. Diabetes is itself a significant risk with COVID-19, but is no longer being dealt with through face-to-face contact. Some Parkinson’s specialists (both in nursing and movement disorder) have been formally redeployed, leaving some people living with Parkinson’s with only background support. From kidney disease to dementia, direct support has been postponed or temporarily removed, with consequences which are hard to calculate. Basic but vital interventions such as physiotherapy are only available remotely (making them practically unavailable for many). Most people are understanding of why this must be, but it does raise the question of how we restore these services and make up for lost time and treatment.

There is also what has been described by experts at the Institute for Healthcare Improvement as the potential for a “Mental Health Pandemic” – an appalling spiral where a combination of loneliness, uncertainty about the future and loss of livelihood combine to cause hugely elevated rates of anxiety and trauma. The immediate issue concerns domestic violence and child abuse, which is much harder to measure without health visitors and social workers being able to check a residence or look out for well-being at school. Calls to helplines have risen by half, and it is appropriate that Northern Ireland is currently urgently considering a Domestic Abuse and Family Proceedings Bill.

This broad social trauma – from the social isolation to the loss of livelihood – will stay with us for years and will have an impact on well-being for decades. Tackling that trauma will require a fundamental mainstreaming of mental well-being in public policy, to stop it leading not only to longer term mental disorders but also (as studies show it does even in relatively mild economic downturns) to a rise in chronic conditions arising from increased levels of obesity or smoking, with consequent reduction in life expectancy associated with these.

All of this – the need for early diagnosis, to treat long-term conditions, and to mainstream mental well-being – must also be combined with the likely ongoing need for tertiary care for COVID-19 itself, whose side effects we still do not fully understand. It is a complex and gloomy picture, so is there any room for optimism?

What all of this will do is reinforce the need for urgent reform of Health and Social Care. Where German-speaking Europe has led the way in the West on tackling the new coronavirus has been in its recognition that the virus needs to be understood and interventions made early to break the chains of infection – in other words, it has a health system build on preparedness (diagnostics and research), not just response (management and treatment). This is exactly what Professor Rafael Bengoa envisages in “Systems not Structures” – a health service built on systems designed to prepare (and intervene early), rather than on structures primarily designed to respond (and treat later).

So, what do we do now? In the immediate term, we face the challenge of charting our way out of lockdown safely. Lockdown was a necessary move to buy time and gain understanding, and there is a strong case for its maintenance while improved testing and tracing is developed. However, it is not even a medium-term policy option anywhere. Extended families cannot remain separated for much longer; friends cannot be kept from meeting all summer; schools cannot realistically remain closed beyond August; even leisure activities cannot be put on hold indefinitely.

Most immediately, however, our Health Service has to return to providing the universal care for which it was established and is renowned. The toll on our collective mental health alone is already difficult to contemplate; once you add in the missed cancer diagnoses, the lost treatment and the delayed care, and the case against long-term lockdown is beyond dispute on health grounds alone. That must now be the priority.

As we do re-open our health system, we should also remember there is always hope. That hope is that this crisis will speed up the much needed transformation of our Health and Social Care services so that they are better placed to intervene earlier and improve our overall health and well-being faster in the very near future. That would be a significant benefit to come out of perhaps the most challenging period of our lifetimes.

 

 

Coronavirus: Thoughts on Northern Ireland maintaining lockdown

In deciding between raising lockdown and maintaining lockdown the Northern Ireland Executive yesterday announced it would be going with the latter until 30 May, although it is leaving itself open to the right question.

It should be emphasised that formally what was decided was maintenance of the regulations to 30 May. This is not quite the same as maintaining all the restrictions, but does establish that “stay home” will remain the basic requirement.

It is impossible to say definitively whether this is the right or the wrong call. It is worth analysing, however.

The case for maintaining lockdown also had in its favour, quite possibly decisively, that it is the simplest course of action and the one endorsed by virologists (the most obvious experts to consult on such matters). It would in fact be a brave Executive which rejected an option which can legitimately be presented as both clear-cut and evidence-based, and lockdown can still be put forward as a policy which minimises the risk from the virus. If you simply look at the COVID-19 charts and you determine that your task is to “save lives” on them, it is hard to make any other decision.

However, the challenge ahead is that, at some stage, the Executive is going to have to be brave. Lockdown may be a straightforward sell, but it is not forever. There are practical realities – such as the fact the UK Treasury will begin to withdraw its financial support (furloughing etc); medical realities – such as the severe effect lockdown is having on people’s health in other ways, not least mentally; and political realities – such as people simply beginning to breach lockdown anyway.

This last reality is perhaps the biggest challenge (not least because it is tied to the other two) – the politicians must stay ahead of the people on what the people regard as “reasonable”. If they do not, lockdown will simply break down in an unmanaged way. This is dangerous – because above all else, it is essential that it is raised in a managed way.

Consider here the counter-intuitive road safety example from Canada.

On a fairly wide four-lane but urban road a 30km/h limit was posted, but traffic surveys showed the average speed on the road was 45km/h – that was the speed people simply felt was “reasonable”, so they drove it anyway.

The authorities then raised the limit to 40km/h. When they did so, the average speed on the road decreased to exactly 40km/h.

The lesson here is that for as long as drivers saw a limit which just seemed unreasonable, they utterly ignored it; but once they were given a limit which looked vaguely “reasonable”, they were prepared to stick to it, even modifying their behaviour to do so.

Thus the higher limit made the road safer in practice, essentially because it enjoyed the consent of those using the road.

Public policy cannot just be imposed. It requires a degree of consent, based on a generally held view that it is “reasonable”.

Even if the decision is regarded as correct by most people, therefore, it is imperative that the Executive gives some idea about how it is going to move out of lockdown. That alone would give people a sense of how they can manage their finances (perhaps prepare their businesses, or workplaces, or whatever); it would help them mentally (as it would clarify how things will or at least may begin to look in the months that follow); and it would likely encourage compliance (because people would sense that maintenance of lockdown is indeed part of a broader plan in the general popular interest).

However, something has to be grasped quickly in the public debate. Lockdown is a truly appalling policy – it causes serious psychiatric disturbance by keeping people (not least children) abnormally away from social and even physical contact, as well as severe damage to general public health and livelihoods. The long-term effects are catastrophic. It is reasonable to argue for a period that they are less catastrophic than letting the virus spread, but it is not reasonable to argue that lockdown should be maintained “just to play it safe” – such an appalling policy with such catastrophic consequences can never be the “safe” option.

This is where, therefore, we need something the Executive is not very good at – transparency. We need to see the scientific evidence upon which it claims it is basing its decisions. A few questions immediately arise:

  • to justify maintaining lockdown it was claimed that R=0.8 in Northern Ireland, even though new cases and confirmed cases are both far lower than in the rest of the UK (despite higher testing) and the R-number for the rest of the UK is stated as lower – how can that be?
  • every single measure (hospitalisations, ICU beds, confirmed cases, deaths etc) is clearly falling except for clusters in care homes – what precisely is being done about care homes and what is the scientific basis for those actions?
  • the practical reality is that for finance Northern Ireland is aligned to the rest of the UK but as a geographical area (and in terms of outcomes thus far) it is aligned with the rest of Ireland – what is the plan to manage that reality and how does it tie in with the scientific evidence?
  • there was some hint that earlier raising of some restrictions was possible – which restrictions, and on what scientific basis?
  • ultimately raising lockdown, regardless of when it is done, is a matter of taking a calculated risk that the balance between maintaining it to keep the virus in check and raising it to enable people to live their lives and restrict the psychological damage has shifted, and that is not an either/or but a gradual process which is itself not a matter of pure science but a matter of judgement – whose judgement, exactly?

In other words, the question is not whether restrictions are being raised in the next few days but a rather simpler one:

  • Lockdown is not forever – so how are you getting us out of it?

Northern Ireland’s position is far from unique. It has got itself into lockdown, but it does not really know how to get itself out again. While German states are falling over themselves to re-open society, interestingly UK devolved governments are going the other way. At some stage, however, Northern Ireland (and Scotland and Wales) will have to take a risk, and this has to be before people start taking their own risks in large numbers. The virus is here, it won’t have gone away at the end of the month, and so we will have to learn to live with it – so we had better be organised.

It was reasonable to take a little bit of extra time, but only if that time is used effectively. The question has not changed, but ultimately the answer is going to have to.

Coronavirus: Can we *imagine* something different post-virus?

Representative organisations and umbrella bodies will, perfectly legitimately and understandably, do what they do and lobby for their members. Demands that restaurants or newspapers be given support to survive are understandable, but are they not an attempt to re-order the world the way it was before for no reason other than it was that way before? What about the world after?

Other than that there have been prominent calls for public money to be used to ensure their survival, restaurants and newspapers do not seem very interconnected. And yet maybe they are.

Over the past 20 years, for example, the “restaurant business” has become the “hospitality industry”. Money which previously went towards newspaper reviews has ended up being transferred to social media managers or even influencers. Profit margins had already tightened. And, as I wrote over a month ago, much of what will happen now will simply speed up what was going to happen anyway.

This is a tragedy for those who had given their lives to setting up a restaurant, of course. Those who find themselves losing out unfortunately as a result of this should, of course, be supported. However, if the industry itself is to be supported, it must be to modernise, not to stay as it was (with low margins and low wages).

So the question becomes, what will we do for leisure and entertainment (and socialising) in the town and city centre of the future?

Newspapers too have given way to social media in many ways. Belfast News is a speedily updated online newspaper; and sites like Slugger O’Toole or Unherd have become the go-to places for commentary; and even the BBC web site exists as a platform for wide-ranging information which might once have been sought in newspapers. Meanwhile the three traditional “big regional newspapers” in Northern Ireland (with a similar story elsewhere) have seen sales decline and profitability come to depend on appealing to advertisers. In Northern Ireland, that already means the public sector. Meanwhile titles such as the Daily Telegraph have just become ludicrous propaganda factories in a desperate quest for relevance and profit.

It is of course politically tempting to try to offer public money up as a way of maintaining businesses for the far side of the crisis. The problem is, those businesses had to change anyway; simply delaying the inevitable transition by pretending things are as they were will not help them.

With newspapers, of course, there is an outstanding problem. A free press is a vital component of democracy. Even in Northern Ireland, where would we be without Sam McBride’s Burned? However, even there, we may need to re-consider what we mean. A free press that investigates and informs, in the way Mr McBride did, is to be cherished and indeed expanded. A free press, on the other hand, which exists just to abuse that freedom to give politically partisan diatribes of irrelevance or ignorance a platform is no use.

So the question becomes, how are we to be informed and educated about current affairs in future?

We can already begin to predict (even though no prediction is entirely safe, of course) that in the same way Blockbuster Video gave way to Netflix, fast-food restaurants will give way to food delivery and newspapers will give way to online sites. They can either carry out this transition themselves, or they can yield to start-ups. Certainly, public money should not be spent on delaying the inevitable.

 

Coronavirus: *Staged* raising of lockdown essential

Many times before on this blog discussion has turned ultimately to the R-number – essentially how many people someone infected with the new Coronavirus will go on to infect. If via social distancing restrictions we can keep this number below 1, we can be content at least that the spread of the virus is slowing (all other things being equal).

It bears repeating that the length of time it takes to carry out positive tests means that we do not know the current R number, only what it was roughly two weeks ago. In Northern Ireland, it would seem that two weeks ago R=0.9 (or maybe just a little under).

This gives a little room for relaxation of restrictions, but really not a lot. We also have to be careful because we do not know the impact of any such relaxation on R for another fortnight.

That is why raising lockdown requires a staged, not piecemeal approach (the Germans talk of Stufenpläne “Step plans”). If we raise in stages we can assess, every fortnight or so, exactly what difference that stage has made to the spread of the virus and general public well-being – and then decide collectively whether to leave things as they are, make some minor adjustments, or go to the next stage in relative safely.

Stage 1

You might cunningly call what we have now Stage 1.

In practice R has been reducing over this period. Therefore at Stage 1, over time, we can probably get to R=0.8 or maybe a little lower (we may well find two weeks from now that that is where we are right now), protect the Health Service, and still at least enable some home working and physical exercise. However, as noted yesterday, there is no social contact – and that cannot last forever.

Stage 2

What we might then cunningly call Stage 2 would perhaps allow for the opening of more open public spaces (parks, cemeteries, golf courses, rivers for angling, zoos, perhaps civic amenity sites) and the enabling of limited social contact provided it is maintained outside and at at least 2 metres (and perhaps with other provisions, such as it must be with direct relatives, life partners or immediate neighbours – making tracing easy if necessary).

At this stage you also begin to re-open the Health Service subject to comprehensive testing of staff and any users. In Northern Ireland, we are likely (but not yet certain) to be able to do this from 11 May.

It is highly unlikely that shops, churches or other enclosed spaces would open at this time, however. It would be too difficult to enforce the 2-metre requirement practically and there is the serious risk that you nudge up to R>1 and then have to go back to where you started to get it back down. The main reason, however, is that you would leave the regulations as they are – merely adding that parks are available for the “physical exercise” component and civic amenity sites (perhaps only by pre-booking) for urgent cases which may have an impact on health. At a push, you may consider allowing anyone, not just a Minister, to attend a place of worship alone for quiet reflection.

Stage 3

Practically, Stage 3 should probably involve the re-opening on a part-time basis of primary schools, but in Northern Ireland a hostage to fortune has been created there and that may prove difficult to achieve formally – so it may be optional, as is intended in France.

At this stage museums and large stores could certainly be considered for re-opening; this would apply especially where they have open spaces and so would definitely include garden centres. Gatherings would still be outside but could perhaps be extended to up to 5-10 people from different households, to broaden social contact.

New Zealand perhaps helpfully talks in terms of your “bubble” to describe social contacts, and this is perhaps a more useful way to look at these stages:

  • at our “Stage 1”, your “bubble” consists only of your own immediate household;
  • at “Stage 2” this “bubble” may be expanded to include direct relatives, life partners, and/or immediate neighbours;
  • at “Stage 3” it may be broaded to include good friends, people you gather with frequently;
  • at “Stage 4” it may be expanded to most or all acquaintances; and
  • at “Stage 5” it may include anyone to whom you can be technologically linked (perhaps, for example, because your phone passed nearby).

This has two significant advantages.

Firstly, to manage the virus itself, it enables tracing – you know exactly who is in your “bubble” and it is then easier to trace contacts in your “bubble” if it becomes necessary (or indeed to trace you if someone in your “bubble” becomes infected or moves close to a known cluster).

Secondly, given justified concerns about domestic abuse or violence during lockdown, it is an easy way of explaining what you are allowed to do in the event you are harmed or become fearful. In New Zealand they put it simply – your “bubble” must be somewhere you feel safe and, if you do not, you must move to another “bubble”.

Regulations would need to change, therefore, to expand “reasonable excuse” to include social contact and, up to a point, recreational well-being including shopping. Nevertheless, the basic guidance generally to stay at home would remain.

Smaller stores and “normal” church services are still somewhat risky at this stage, however, and eating establishments are definitely still not an option. There would simply be too much of a risk that these would provide the decisive nudge to R>1.

Stage 4

After a period it is just about possible, if you still find R<1, that you would try one more stage even without a vaccine or a treatment.

This stage essentially takes us to “Sweden” (where the current estimate is R=1.4 but this would perhaps be lower if it had previously been R=0.8 for a while).

Personal businesses – hairdressers, beauty salons etc – may now re-open, as could libraries, restaurants and bars (particularly those with outside areas) with a “no standing” rule and of course an ongoing 2-metre requirement.

It may be that nose-and-mouth protection would be required for adults in shops and on public transport, but these could then perhaps re-open with a 2-metre advisory retained. Gatherings could perhaps broaden up to 50.

At the very outside, you may even making limited allowance for team sport at this stage, on the provision that those participating are clearly identified (and perhaps even tested in advance) for future tracing if required.

Stage 5

In extremis, you may even go further and allow a return to relative normality (except probably large or very enclosed gatherings) ahead of a vaccine if you have some sort of technological breakthrough which allows it. This may include a compulsory phone tracing app, temperature screening machines in every public building or business, and/or obligatory antibody tests for all.

However, taking the cautious staged approach, even with the technology this would not be likely this calendar year.

Conclusion

It is hard to envisage getting much beyond Stage 3 pre-vaccine, but this perhaps gives an outline of what (and why) the stages would be.

They may be subject to some reasonable minor adjustment each fortnight, but if you set the stages out in advance it may stop the nonsensical piecemeal attempts at an à la carte approach currently being suggested. It would also give people a clearer idea of what lies ahead, even if no one yet knows when!

Coronavirus: What even is “lockdown”?

I wrote some time ago of the need to define our terms when it comes to “lockdown” and other aspects of the social restrictions we are currently living with. Of all of these, “lockdown” has probably become the most loosely defined.

R-number

Let us first return, however, to the R-number – the reproduction number, or the number of people an infected person infects (by definition in almost all instances within about 4-5 days of first being infectious).

The aim is to have R<1; at that stage, the spread of the virus is no longer accelerating. There is still spread, but it has slowed; this means, if the Health Service is currently managing, it is sure to continue to manage.

This is of course a crude measure. In practice, even if R<1 across an entire population, you may still find R>1 in certain regions or among certain groups (most obviously and riskily residents of care homes). If R>1 among people most vulnerable to the virus, you may still find the Health Service coming under pressure and the death rate rising, at least for a period, even though the rate of infection across the entire population is declining.

So the overall number is not a perfect measure – nothing about measuring this crisis is perfect of course – but let us run with it and how it relates to lockdown.

R=0: British Virgin Islands

With absolute lockdown, in principle you should be able to reach R=0.

In the British Virgin Islands, population 30,000, this is being attempted. If you lock down the entire population absolutely – i.e. by an absolute curfew – in principle there is then no way for the virus to spread. Initially, the virus can only spread within homes; but once everyone has either recovered or sadly died, then the virus no longer exists among the population and has been eradicated (at least, until you open your borders).

Absolute lockdown means what it says on the tin – no deliveries, no grocery shopping, no nothing. As soon as you allow any of that at all, your lockdown is not absolute…

R=0.2: New Zealand

If you reach R=0.2 or perhaps even R=0.3, you slow the spread of the virus to the extent that it is fully under control and there should be no further transmission which is not immediately traceable. New Zealand believes it has accomplished this.

New Zealand implemented an early “Alert Level 4” set of restrictions, what might be referred to as relative lockdown. Similarly to across the UK and Ireland, New Zealanders were allowed out only for exercise, groceries, medicine and laundry (and some other specific purposes), although there was also an absolute bar on takeaways, or on pre-cooked food being delivered.

New Zealand has now raised this to “Alert Level 3” (allowing takeaway food, for example, but also re-connection with family members and care givers).

This is an exception in this list given New Zealand’s geographic isolation – it is for this reason that its own public health advisers say that what it has done could not be achieved elsewhere.

R=0.7: Italy

Italy was the first European country to implement what may be described as a full lockdown, with the clear intention of protecting its health system and reaching R<1.

The exact details of the lockdown varied and vary from region to region, but broadly they involve an absolute curfew with people allowed out only to shop for basic necessities (groceries and medicines). Very limited physical exercise is generally allowed (although for a period in Lombardy it was not), but within a very small radius of home and strictly alone.

The hope is that R=7 in Italy although there is some evidence it has not in fact sunk that low across the whole country (R=8 seems likeliest). This has given the Italian Government confidence to plan some raising of restrictions, but as has been noted elsewhere on this blog, you never absolutely know the impact of any easing of restrictions for at least two weeks. So Italy’s plan is to go into fortnightly jumps – 4 May, 18 May, and then early June.

Spain and France both largely followed Italy, and so will most likely largely follow it out again. There is one notable exception in sport – Italy clearly intends to try to restart professional club football, but France has given up.

A very interesting question will be what happens in the period 4-18 May, a period during which Italy will basically have the same lockdown in place as the UK has currently…

R=0.8: UK & Ireland

The UK and Ireland currently have what may best be described as a relative lockdown, believed to be enough to move to R<1.

The lockdown is relative because there is still a considerable degree of freedom. People may go to work if they cannot work from home; many stores (not just for groceries, but also alcohol, takeaway food and hardware) are open; and physical exercise is relatively unrestricted (especially in England, Scotland and Northern Ireland). Nevertheless, social contact with people from outwith the household is prohibited, and on that basis “lockdown” still seems a reasonable designation even though strictly it could be argued this is merely “strict social distancing”.

The UK has stated that currently it believes it has reached R=0.5-1.0; Ireland has said 0.7-1.0. The concern is those lower numbers are actually an “Easter Effect” (see below) and in fact they are at the higher end – giving little room for maneouvre in early May.

I have a concern, which I will come to tomorrow, that the sudden changes in communications by the Irish Government symbolise evidence that despite “lockdown” in fact R=1 because testing has been returning too many false negatives (this is a particular risk with drive-through testing). If so, it gives very little room for manoeuvre – but also brings into question the efficacy of lockdown as implemented.

R=0.9: Germany

Germany’s “lockdown” was of course wildly variable from state to state, and has perhaps only become more confused since. Nevertheless, in broad terms, it is best described overall in the words of its Chief Virologist as a “mild lockdown” – restaurants and most shops were closed and social contact limited, but (at least away from Bavaria) there were significant freedoms still allowed which were not allowed in the UK, Ireland, France, Italy or Spain.

Initially it was thought a combination of these measures and the population’s stereotypical response even to treat guidance as strict regulation had been very successful, and that the country had reached R=0.7. However, this was subsequently dismissed as an “Easter effect” (Good Friday in particular is an absolute day of rest in Germany; cinemas and sports grounds do not open anyway, for example), and the figure revised up to R=0.9 by the time states had begun to insist on lifting some restrictions.

As a matter of pure personal opinion, the decision to open shops at R=0.9 baffled me. Germans in most states were already allowed to meet up with close family members and perhaps this could have been broadened (what the New Zealanders call “growing the bubble”) or at least made consistent; however, a lot now hinges on the Maskenpflicht (the requirement for nose-and-mouth-covering in enclosed public spaces. If it turns out that masks are as ineffective as the WHO seems to think, the decision to focus on shops rather than limited social contact could prove to be a profound error – but one, notably, forced through by state governments against the better judgement of some federal authorities.

States have now opened all shops subject to compulsory nose and mouth protection (albeit with various restrictions on their ability to trade or otherwise over a floor space of 800 square metres or in shopping malls). There is early evidence this has already led to R=1.0, although it will take some time to be absolutely sure.

R=1.4: Sweden

Irish advisers have been very clear that R=1.2 is still manageable – the sort of level from which the virus can be brought back under control relatively easily to protect the Health Service; they believe R=1.6 is retrievable, but would require considerable intervention. Sitting at the midpoint of R=1.4 currently is Sweden. Sweden, of course, has no lockdown.

The Swedes themselves are sometimes frustrated at being seen as complete outliers – social contact is in fact restricted, through prohibitions on large gatherings and requirements to stay two metres away, even in restaurants (where in fact customers may not stand up). However, by the standards of Western Europe, outliers they are, as the only country which has not even attempted to get to R<1.

The Swedish authorities are quite overt that they judge there is an acceptable level of infection (and therefore, frankly, death) in return for fewer restrictions on society which can remain in place if necessary for years until a vaccine is found. They point to other countries, such as Denmark and Norway, now adopting their strategy in broad terms, accepting that lockdown cannot be maintained forever; and to Germany and Italy grappling with how to get out of lockdown without accepting that moving out means inevitably R>1.

Sweden has closed individual restaurants for breaching regulations, but there is no sign whatsoever that its “special course” will be fundamentally changed.

Conclusion

We can perhaps define “lockdown” therefore as an intentional attempt to use strict “social distancing” in order to slow the spread of the virus before pharmaceutical interventions (treatments, vaccines or whatever) become available.

Instantly, we can see the challenge, however. Lockdown is not forever. If you do it, you have to work out how you will get out of it; however, if you do not do it, it means tolerating more grief and suffering at the outset.

There are legitimate choices here, none of them easy. As Freddie Sayers writes superbly here, the debate about lockdown is not a debate between good and evil.

 

Coronavirus: the case for maintaining lockdown

Anyone who follows this blog will know that I regard lockdown as a necessary evil. It is far from the easy option that many of its proponents suggest it to be, but it does give us breathing space.

There is also, for the record, a body of academic evidence which suggests lockdown with curfew is not necessary and achieves no purpose. They note:

  • the differential death rate in Sweden versus its neighbours can be attributed to other things (poor preparation, low testing, bad tracing, population profile, failure to protect nursing homes, etc);
  • Germany has good outcomes despite a mild lockdown (in fact most state never had a curfew – i.e. there was no legal bar on leaving home);
  • that in fact what is called “lockdown” is not lockdown because people are in fact still allowed out, notably to shops (and thus to infect and be infected).

Nevertheless, like most issues around the virus this is far from settled, and evidence from places as far away as New Zealand and Greece does seem to suggest an early lockdown can make a considerable difference to fatality rates (although exactly which aspects are most helpful remains open to debate).

The argument for raising lockdown is in general fairly clear, and is being followed in many Western European countries including Germany itself. As we pass the peak in infections and hospitalisations (particularly for critical care), we can begin to open up again because we have “flattened the curve” and we are sure that hospitals will not be overburdened.

Very strictly, we can afford to do this for as long as R<1 – where R is the “reproduction number”, in other words the number of additional people infected for every one person who is infected. If R>1 the virus spreads exponentially – if one person even merely infects 1.1 other people on average, then they infect 1.1, and they infect 1.1 and suddenly the virus is spreading rapidly again. However, as long as R<1, the spread is contained; it carries on, but at a decelerating rate, meaning health systems can cope.

As noted yesterday, with no restrictions it seems R=4.8 or so (known as R0=4.8). However, on the basis that restrictions have driven this figure down to around R=0.7, as initially suggested in Germany and, tentatively, in the UK and Ireland, why on earth would be not lift at least some restrictions as part of the balance between liberty and life, maintaining R<1?

What is R?

The first risk is we may have misjudged R.

In fact, Germany’s public health institute (Robert-Koch-Institut) now suggests R=0.7 was a specific feature of Easter week, when people were less mobile even within the confines of lockdown, and that in fact R=0.9. That is much tighter, obviously to the Grenzwert (“border value”), and means that restrictions need to be eased with significant caution so that the “border value” or tipping point is not breached.

When is R?

The big problem is that if R>1, even with a really good testing system we would not see it in the data for two weeks – the length of time it takes enough people to show symptoms, get tested, the rest to be evaluated, and the authorities to be notified.

So, for a period of two weeks after we raise some restrictions, we literally will not know the value of R. We will just be estimating without clarity. That is the danger.

Why R=1?

The other question here is why are we so obsessed by R<1? Surely, even at R=0.9, the virus is spreading?

Yes, and that is the core point. No attempt is being made here to eliminate the virus, just to control its spread so that it is manageable in the expectation of working vaccine becoming available to the population perhaps by summer 2021.

That is why no country is talking about allowing mass gatherings before a vaccine; and thus why we need to forget about crowds at football matches, summer holidays abroad or even pubs opening for a long, long time.

How about R=0.2?

Some virologists argue, however, that further weeks even of Germany’s relatively mild lockdown (so surely of the UK’s or Ireland’s even tougher restrictions) would deliver R=0.2 – so it would take five people to be infected on average for one other person to be. Those figures are for Germany where there are surely rather fewer infections in total to begin with (even though better testing has revealed more), but there is no particular reason to believe it would be any different in any other Western European country given that fundamentally the cause of the decline is lockdown, not the number of infections to begin with. Although it remains unclear, it is this which may account for the dramatically lower infection and death count in Eastern Europe (where lockdown was applied and adhered to comparatively much earlier).

At R=0.2 or even R=0.3, some virologists argue, you could in fact begin to think in terms of tracing every infection and potentially eliminating the virus outright (at least from the jurisdiction in which R=0.2). They say this with no certainty, but they put it forward at the very least as something to consider – and indeed something which may become necessary to try if no workable vaccine appears or immunity in this particular case is shown to be very limited.

Keep lockdown?

So the question arises, for all the strain that it undeniably causes and indeed the debate about whether it is really effective at all, should we therefore maintain lockdown – either to be absolutely sure R<1 or even to see if we can get to R=0.2?

Given that the financial packages have been set out to protect livelihoods as best as possible through to the end of June, and that the Health Service in general could begin opening up (for example re-starting elective care), this option is surely worthy of consideration. After all, even three weeks more of lockdown would surely see R decline further, even if only so we could be secure R=0.7 before raising any restrictions; if we found at that point that there was some chance actually R<0.5, then there would be a case to go for it and see if we could get it right down by June. In turn, it would also enable more time to put tracing (whether by trained individuals or technology) in place with the precise intention of reducing significantly the prospect of having to do lockdown again, even in the autumn and even if the virus continues to spread.

This would be a classic case of short-term pain for long-term gain. No one wants the current restrictions to remain in place for a second longer than they have to; but there is a serious risk that putting the lights to “red-amber” too early will see people behave as if they are already “green” and with the result that we will be back where we started in the autumn.

That is a fate to be avoided at all costs. The question is whether lockdown is an essential, or even viable, tool.

Coronavirus – how to think our way through

How do we think our way through and beyond the weirdness of coronavirus lockdown? 

A month ago this weekend, if you had pondered what you might do about eating that evening, you would probably have contemplated eating out, getting takeaway, or cooking in. That seems to be a wide range of choices, and it seems to cover every base.

It is unlikely that you would have contemplated going out into the woods to try to find some food. That was not on your options list.

Yet all over the world, or even in this part of the world at another time in history, a lot of people would have contemplated that latter option; indeed, some would have (had) no other option. And this is not as far away as you think – during its current lockdown, a couple in Italy was arrested for breaking curfew having got lost in a forest looking for asparagus to bring home.

H_ThoughtsThe point here is that although we believe we think freely, in fact we only think within very limited confines – usually determined by our upbringing and the culture of the community around us.

We can visualise that above. The outer square is all the options we could have considered for getting food in the evening; the larger inner square represents the confines within which we actually thought (thus ignoring going out to pluck fruit, bring home roadkill, grow our own food on our own property, or whatever).

Now, we have to add another, smaller inner square – those are the options which are open to us in the current context, with restaurants closed and non-essential journeys prohibited. Eating out has ceased to be an option; and in fact, strictly, takeaway is only an option if we can deem it “essential”. So our “thought box” is even more limited than it was a month ago.

Ultimately, to think our way through this whole thing, we may find these boxes quite useful. For almost everything, even once many of the lockdown restrictions have been lifted, the box within which we think and make our choices will have shifted.

H_ThoughtsSo not just during the lockdown but also when we emerge it, we will find the confines in which we think and make choices will have moved. Above, the box will emerge the same size as it was before, but slightly shifted – we may well be more inclined to opt for food order services (in the UK, the likes of Simply Cook, Rule of Crumb or Ocado) or even to grow our own food in our own allotments or gardens, and less inclined to queue in fast-food restaurants where there is no real time gain but a latent fear of catching the (or indeed any) virus.

The same will apply to every aspect of our lives. Our choices in terms of how and where we work; which meetings are necessary or desirable and which are not; how we travel; where we go on holiday; and so on will all be subtly shifted a little. The knock-on effects of this may be quite profound – we may see working hours made a lot more flexible as people avoid crushed transport in rush hour; meetings still carried out on Zoom, Hangouts or Teams rather than in person with more work still done from home; holidays taken closer to home and foreign properties sold; and decisions made more with a view to collective, population health rather than just individual, personal health.

Most of all, the whole notion of how we think about others and choose to relate to them will change – and ultimately probably in good ways, as it is a chance to reject the skewed priority we gave until recently to “fame”, “success” and “celebrity” in favour of the much more important priorities of “kindness”, “love” and “companionship”.

In other words, we are all aware that we are going through a period of intense disruption, and that can make us anxious; currently we are almost grieving for a way of life which we know will never be restored in quite the same way. But if we think it out in our “thought boxes”, and consider that all that has happened is the confines have shifted but we still have the same thought capacity we always had, then we will perhaps be able to think our way through all of this and come out better on the other side.

Coronavirus – and the need for entertainment

Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty is a fascinating outline of the essentials and challenges in tackling poverty across the world. It is fascinating because it does something very few people actually do – it asks the poor what they think. Using observation, it shows that choices made by people living in poverty often seem counter-intuitive, but make sense when the circumstances and the human condition are understood.

One chapter concerns a gentleman in rural Morocco. He is only able to work half the year and as a result is barely able to clothe and feed his family, who lack even shoes. Yet he has a television. The gentleman himself explains that he wants shoes but needs a television, because without it he would have no connection to the outside world and no regular source of entertainment. Connections and entertainment are not optional for human beings – we need them to survive.

Whatever happens in the next few months we will not face the same level of grinding poverty as that gentleman in Morocco. Nevertheless, we are about to find out that choices made in extreme situations are not necessarily the ones we would predict – even our own choices. As large parts of the Western World head into lockdown for some months, we will learn a thing or two about what we need versus what we merely want.

Twitter accounts such as David Steven (in Pisa) already give us a fascinating idea of the choices people make in lockdown. Yesterday, he reached the conclusion that people in lockdown require some kind of entertainment, and suggested some kind of football tournament.

The notion that footballers are “vital workers” is immediately counter-intuitive and instinctively outrageous, and yet we may expect this to be a growing demand. If testing for the virus is ramped up so that there are more tests in a day than there once were in a month, it will become possible to hold games behind closed doors safely. Indeed, we may expect this to become the case just as we are collectively getting really bored, so it may be just the trick to keep us all inside on a beautiful May Day weekend.

Sitting inside on the sofa on a sunny day watching football for our own good? This could be just one example of how we learn a lot about ourselves in the coming months.