Category Archives: International

Coronavirus – UK and Sweden’s standing diminished

Sweden’s Chief Epidemiologist Anders Tegnell admitted yesterday that the country had, essentially, got it wrong by not shutting down tighter. Northern Ireland’s Health Minister Robin Swann also said there were things he would change. Still, UK Prime Minister Boris Johnson, who has overseen what may well be the world’s worst death toll per head in England, denies any errors whatsoever.

At least Dr Tegnell admits now that there were errors – in fairness, he had always warned that nothing was certain. Mr Johnson continues to deny it all, claiming that the rest of the world stands in awe at how the NHS has survived and then talking vaguely about “world-beating” testing. Such delusion is getting genuinely scary now.

Both the UK and Sweden have done themselves significant damage beyond the unnecessarily high death tolls they have inflicted upon themselves by not learning from others and refusing to try to understand the virus properly. They had previously each commanded a degree of global respect for their public administration and public health expertise; that is now hugely diminished.

The UK in fact exports expertise in public administration, but it is hard to see too many buyers for this now. The mishandling of the Coronavirus, symbolised by the nonsensical sight of two thirds of MPs queuing up for half a mile to vote to stop the other third from voting, follows the farce of Brexit in which the UK has overtly opted to crash its own economy and opt out of global protocols for everything from medical regulation to fighting terror. Far from looking on in awe, the rest of the world can scarcely bring itself to look on at all, such is the scale of the cringe which inevitably accompanies doing so..

Sweden too was widely regarded as a country of unrivalled expertise, not least in public health where life expectancy has risen to among the highest in the world. For weeks if not months the rest of the Western World seriously looked at Sweden and wondered if Sweden could be right and the rest of the world wrong – for many this was a serious possibility, such was the respect in which Sweden was held. However, as hundreds of people continue to die every week in Sweden while almost no one dies in any of its neighbouring Nordic countries, the view has shifted dramatically; it is dawning on everyone, including Sweden’s public health leadership, that after all the rest of the world was essentially right and Sweden catastrophically wrong. Even the UK has worked out now that testing is important, but still Sweden stumbles along effectively pretending this is just a bad (or actually not even a bad) ‘flu. Respect has turned into bemusement, which will soon give way to outright ridicule. Sweden’s reputation for sound management and excellence in public health will be undeniably tarnished, both at home and abroad.

Both countries will struggle to deal with the consequent adjustment, as others take over as beacons of sound public administration and expertise in public health. The UK in particular will have to ask itself fundamental questions about where the ongoing centralisation of political and economic power, at least within England, has ended up – what has happened is that an ever declining number of people with an every declining amount of expertise have ended up taking all the decisions, often in complete ignorance. Brexit and Coronavirus are obvious and major shambles, but they are accompanied by all kinds of minor ones, from a collapsing higher education sector to the farce of the rising costs around the HS2 rail project. Sweden too will face the trauma of having to recognise that those they trusted to take them through this challenge failed abjectly – does its whole system of expertise ahead of politics really work?

Both countries, their standing diminished, will now face the challenge of reform. Will they be able to meet that challenge? Certainly in one case, it is very doubtful.

Coronavirus – podcast

Was good to join Slugger O’Toole for a podcast on the Coronavirus, the Northern Ireland Executive’s response and some international comparisons on YouTube.

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: UK Government drifts from embarrassment to farce

The reason there are so many conspiracies around the Kennedy assassination is that people cannot get their heads around the idea that some random loner shot dead the President of the United States. The very notion makes us feel insecure and fearful. So we choose not to believe it – at least if there is a conspiracy, we can imagine someone was in control and we do not need to fear that such things can happen entirely at random. Yet the fact still remains that they do happen at random, and indeed that Kennedy was shot by a random loner.

Likewise, people cannot get their heads around the idea that at a time of huge crisis the UK Government consists of a bunch of complete incompetents. This also, even if we don’t like Tories very much, makes us feel insecure and fearful. So we invent things. It actually makes us feel more secure that they are evil geniuses intentionally trying to get rid of old people, than it does to confront the reality that they are just simply useless and do not know what they are doing. Yet the fact still remains that the UK Government consists almost entirely of useless incompetents, not least its Leader.

The simple fact is that Boris Johnson has not the first clue what he is dealing with. In a 13-minute “address to the nation” (which ended up being recorded in chunks over two days) he did nothing but bumble idiotically because he had no idea what he was talking about. He talks cluelessly in Parliament about the virus being in the “water supply” when it is actually airborne. He can deal only in slogans, not detail. He fundamentally has no idea what he is doing and the fact that he is a convalescent from the disease itself, and is clearly not fully recovered, only makes matters worse.

His colleagues are little better. The result is that the UK ends up with someone on television trying to explain why in England as of now your cleaner can visit your home but your significant other cannot, or with someone at a media briefing arguing that it is reasonable to visit a house and enter every room with a stranger to view it for potential purchase but not to enter just one room to see your own mother. If this seems idiotic it is because, simply, it is idiotic.

Just as one example of how dangerous it is, we have the additional idiocy that people in England can now travel anywhere when the one thing that is certain about managing the virus through lockdown is you do not want people moving around too much. The whole point, for example, of the Korean approach is that you are able to identify quickly if there is a problem in a particular neighbourhood. If people are moving around too much (and you have no apps because, you know, that doesn’t seem to have happened…), you are going to find that a lot more difficult. And yet somehow, while people still cannot meet neighbours for a barbecue, they are allowed to drive from Newcastle to Cornwall or from Norfolk to the Lake District and go to an enclosed garden centre when they get there.

It is demonstrable that the UK Government’s response was the worst of any large European country’s during this pandemic simply from looking at excess deaths by region. Whereas other countries may have suffered higher excess mortality because a particular region was hit so hard that its health system collapsed (but then managed to stop infections from spreading quickly elsewhere in the country), in England every single region bar one has seen excess mortality more than 50% above average. The country is particularly densely populated but faster action even simply to stop people travelling about widely would have seen spread contained largely to the London area and some other hotspots – yet the first step out of lockdown, incredibly, is to allow people to travel around again. It’s sheer lunacy.

It is essential, therefore, that we do not try to over-complicate what is going on here. There is no evil mastermind behind all of this. The UK (and particularly England, as it happens) is just being led currently by a bunch of political ideologues who, when it comes to the business of government, are utterly clueless. We are experiencing farce and embarrassment because they are farcical and embarrassing. The result is sheer idiocy because the government consists of idiots.

Even though this is quite scary, we must avoid conspiracy or complication about it – not least because, especially now we have a proper Opposition, we need to get the current incumbents out as soon as possible.

 

Coronavirus: Lockdown is absolutely not the “safe” option

Please note what follows is merely an analysis piece.

For the avoidance of doubt, the public health advice in Northern Ireland remains Stay Home, Save Lives.

Shortly after my post on Northern Ireland’s decision to maintain lockdown regulations, new figures revealed that in the five weeks to 1 May (essentially the first five weeks of lockdown – the last few days of March and the month of April) 704 people died in Northern Ireland additional to the number who would usually die during that period (“excess deaths”).

We would expect excess deaths, of course, given the coronavirus crisis. There is a problem, however. Of these deaths, 493 followed a positive test for COVID-19, an alternative diagnosis of COVID-19, or were simply “assumed” to be associated with COVID-19 by a GP.

That leaves 211 people over and above the usual seasonal number who died of something unassociated with COVID-19.

This is a serious problem, and it is not getting enough attention.

Profoundly, it leaves two options. Either people are dying of COVID-19 in ways so obscure that GPs are not even “assuming” COVID-19 even when it is present, which is worrying in terms of our understanding of the virus and the disease; or, probably likelier, people are dying because of lockdown. Neither of these options is tolerable.

We need to determine which it is urgently.

If, somehow, GPs are unable even to “assume” COVID-19 when it is present and causing death, that has major implications for our understanding of the whole thing. What are we missing?

On the other hand, if a lot of deaths are occurring because of lockdown we need to face the fact that at some stage in May lockdown itself will be causing more deaths in Northern Ireland than COVID-19. Maintaining lockdown is, therefore, anything but the “safe” option.

Of course, the balance is more complex. Not maintaining lockdown may lead to a rise in deaths associated with COVID-19, and there is a balance to ensure this does not then exceed the “benefit” of not having lockdown.

However, if anything the balance swings the other way. Those 211 deaths are immediate – but how are we counting lives ended early (or indeed not fully lived) because of lockdown over the coming years and even decades? GPs are reporting the worst mental health crisis in living memory.

On top of this, we need to leave open the possibility that the scientific basis for universal lockdown is not entirely safe. Countries such as Iceland and even Germany have secured much better outcomes without implementing such harsh social restrictions (what they did do was test early and test often). Lockdown in the UK was based on modelling from Imperial College London which itself was based on questionable data from China, not on actual forecasts.

This is made more urgent by updated data from elsewhere in Europe. There is increasing evidence that the actual death rate from COVID-19 is in fact much lower than originally assumed. Where Imperial initially assumed close to 1% of people who got the virus would die with it, studies in France have put this figure at 0.52% and in Germany as low as 0.37%.

That is not to say that the case for universal lockdown is totally insecure based on data from nearby countries. For example, having opened shops over the past few weeks, there is serious concern that Germany is already now at R>1. We also do not fully understand the longer term effects of the disease.

None of this is to say that the decision to maintain lockdown was or is the wrong one. However, the combination of non-COVID-19-related deaths and an imminent mental health pandemic means it is most certainly not the “safe” one. The public debate needs to be very clear about that.

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: *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: Lockdown – and finding the right question

I made the case earlier this week for maintaining lockdown and then the next day for raising it – but I could not provide a definitive answer to the question.

That is, of course, because it’s the wrong question.

Here we move away from biology, epidemiology and medicine on to something I have at least some expertise in, namely public policy.

What many people miss about public policy is that it is directed by the people (actually by humans), not the politicians. If we wish to keep the public onside with expert decision making in a crisis, we have to communicate with them and enable them to act not as social studies or economic units, but as humans.

Consent

You can only govern by consent – and that means you can only lockdown by consent.

This was exactly why lockdown could not be put in place too early. It is not in our nature, particularly in the West, to break off human contact and restrict freedom; so it had to be done in such a way that ensured people would be adhering to it voluntarily through peak.

As Jonathan Freedland points out, the fundamental punishment we assign to people who break the rules of a civilised society in a significant way is to deprive them of their liberty.

Depriving the entire population of their liberty is not, therefore, a long-term option in a civilised society.

Therefore the question is not whether you raise lockdown, but how, to ensure the consent of the people is maintained.

Communication

It is easier to sell an average policy well communicated than a good policy poorly communicated. Communication is more important, therefore, than the detail of the series of restrictions you intend to maintain.

It is extraordinarily difficult to ensure that communication is maintained clearly even as people begin to broaden their freedoms once again (note how I have phrased that – people will increasingly make their mind up, regardless of that the policies or regulations actually say). Some countries, notably France and the UK, use war-like language (we will “defeat” the virus; it is an “enemy”) to try to maintain social cohesion. The US talks more in terms of a “plague” and being “smart”. Germany talks more in terms of “caution” or “risk”.

As I noted at the weekend, Sweden and Ireland last week displayed outright panic – “warning” of more or extended restrictions if people did not comply. This is rarely effective. Once you present lockdown (i.e. deprivation of liberty) as a government punishment rather than an act of civic solidarity, you will inevitably lose public consent.

Not everyone gets it wrong, however. Sir Keir Starmer, leader of Britain’s Labour Party, struck the right note, saying: “The government is behind the curve on this. Simply acting as if this discussion is not happening is not credible. The public have made great sacrifices to make the lockdown work. They deserve to be part of an adult conversation about what comes next. If we want to take people with us and secure their consent, this is necessary now.

Actions

Therefore, how the next stage is done is more important than what is done. It is worth, as ever, being clear about what the question is.

The real penalty in lockdown is deprivation of liberty, but the most fundamental problem of all is the lack of human contact (in all senses, but let us stick with the general social meaning for now). So, the question is how we enable this without greatly increasing infections.

I am unclear, in terms of public policy, that the German route of focusing on shop openings is the way to go. Even as it stands currently, the highest risk is when we congregate in shops for “basic necessities”. Allowing us to congregate in more shops for non-necessities is surely only to enhance the danger, without particularly tackling the absence of contact with friends and family. An economy based on shops is not a real economy anyway – shops are the mediators, not the core production.

The prime aim should be to re-open open spaces of all kinds, and allow people to meet outdoors or in large public spheres provided they respect distancing. This is effectively what is happening anyway, so simply stamping it with approval buys another few weeks of limited spread of the virus while contact, of sorts at least, is allowed. In case the weather turns bad, there may be a case for opening large indoor halls (say, for badminton or gymnastics) as well, subject to a booking system – anything which enables people to meet while keeping the required physical distance, and in a public arena where this can be assured.

It is worth noting what the objective is here. It is to enable social contact while maintaining social distancing. After three weeks we will see what kind of difference it has made – both to the spread of the virus and to public attitudes – and then we can choose our next steps. As humans

Conclusion

The idea here is to reframe the question, and to raise lockdown in a way which is human.

The objective is to enable people to do what matters most, without greatly enhancing the danger to them from the virus. It is important to think of it and communicate it in these terms, rather than more abstract and technical terms around “opening the economy” or “returning to normality” – because if we do not do it in a way we respond to as humans, we will soon find ourselves back where we started.

 

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.