On 26 November 2020 I published this piece on Covid-19 but, as so much has happened since then, an update seems very necessary.

In late November 2020 it felt like we were surfing down the face of a “second wave” of the Covid-19 pandemic. There were one or two “good vibrations” in terms of progress with vaccine development but it was scary because, sadly, a lot of us were and are still going to experience “wipe out”. I deliberately used the surfing analogy because there had been more than a small element of wilful risk taking that had brought us to this ‘place’. As of 2nd December the latest lockdowns were replaced by a set of restrictions, dividing the home countries into ‘tiers’, in order to let the populatiuon “have a Christmas”. These tiered restrictions seemed likely to last until March 2021.

Since my piece in mid-June, much of what I then feared (even predicted) came about. The UK’s so-called “world class” track and trace system failed miserably, and for the reasons that have been obvious from day one:

It lacked the capacity to test widely

It lacked the ability to reach enough ‘contacts’

It depends on people to report symptoms and then, diligently, self-isolate

From the very earliest days of the UK’s pandemic, certainly before the initial ‘lockdown’ in mid-March 2020, it has been clear that the extent of asymptomatic disease, and transmission, was underestimated and driving community incidence. Its effects were compounded by our UK government’s flip-flopping on social distancing, and on the use of face masks and, critically, it was also compromised by the overwhelming desire to “get back to normal” and to re-open the economy (see “Shop til you drop” and “Tombstoning..” elsewhere in this thread). In the summer of 2020, when Covid-19 appeared relatively under control, it now appears our population was used, guinea pig-like, to experiment with what happens if you let the brakes off in various ways. We were told we could go on holiday. In the UK people streamed from areas with higher incidence rates to areas with lower incidence. People relaxed whatever adherence to anti-Covid measures they were observing, understandably enough, and largely forgot about social distancing. Young people, especially, threw themselves into party mode. At the same time we were told to “eat out to help out” and many holiday hot-spots became “super-spreader” locations. We now know that those who did venture abroad, especially to Spain, brought us back a new strain of Covid-19. Schools re-opened and, significantly for some local ‘spikes’, so did Universities. It seems nobody thought that mass movement of young people to University halls of residence across the UK might be a problem – or did they?

In the face of regional disquiet over the UK government response, and rising infections in university cities, the devolved administrations began to apply their own (some might say improved) responses. We already had confusion about what Covid-related restrictions applied, and the inevitable anomalies were (and still are) wilfully exploited by some. It just got even more confusing. Only the Welsh authorities imposed widespread travel restrictions, while in Scotland there were regional closures.

As I saw it, a significant proportion of the UK population was (and is) not disposed to following guidance, never mind instruction. Whether this is because they are incapable of understanding, or are wilfully disregarding, the importance of their part in suppressing transmission, I don’t know. With the population suffering, what was called, Lockdown Fatigue, pent up frustration, and being somewhat encouraged to anticipate a “festive season”, one had to hope that enough common sense prevailed. I thought it was highly likely we would see a third wave of infections in the new year. but actually the third wave was already under way.

Then, in short order, we got the first deliveries of two approved vaccines and the government approved plan for a 5-day family Christmas was belatedly abandoned and cut to one day. Into January and the first of the so-called “variants” was acknowledged, but we now know that one that had emerged in Kent in September began driving the third wave well before Christmas. It was this that caused the abrupt cancellation of Christmas festivities, and the imposition of another total lockdown.

Fast forward to now, late february 2021. In the UK we have a rolling programme of vaccination, with 2 vaccines available and more waiting to come ‘on stream’. 17 million + people, in the clinically most at risk groups, have had their first dose of a planned 2-dose vaccination. The essential second dose is not now to be administered until 12 weeks after the first, which is not how the designers tested it. The programme is going so well that the government has now decided they have the ability to vaccinate all of the adult population by the end of July 2021 with the first dose.

The third wave has seen us pass the ghastly milestone of 100,000 dead (and as I write this update, passing 120,000). Although the third wave seems to have peaked I can see no reason why the death toll will not eventually pass 150,000 [note this figure eventually rose to more than 240,000]. Nevertheless, hand in hand with this perceived ‘peaking’, and the available vaccine programme apparently going well, the government has decided we can plan for coming out of lockdown. It would appear that the ‘data’ supports a cautious relaxation of restrictions, with several weeks between each relaxation to monitor the effects on infections. The official view is that this is the last of the lockdowns, that this direction of travel is “irreversible”, but this is where I have fears for a fourth wave.

We know that humans (at least in the UK) will not do as they are told. We know that sometimes this is because the don’t understand, sometimes because they don’t care, and sometimes because they are confused by variable and nuanced government messages. We know the economic and political imperative to reopen commercial life is powerful. We know the virus will continue to mutate. I think it reasonable to assume the government has learned epidemiological lessons which, I believe, it experimented with throughout 2020. I believe the government anticipates a fourth wave but feels it has enough data to pin its hopes on vaccines that can limit the size of that wave, and that can be ‘tweaked’ to deal with serious mutations, and in the context of coming summer weather which naturally suppresses the virus. Experience in treatments and the development of antiviral drugs seems to suggest that, for most, infection will not result in hospitalisation and death. Whether this holds true for all future mutations of the virus remains to be seen.

In the end I believe the success or failure of managing Covid-19, going forward to the winter of 2021 and beyond, will depend on whether people can remember, and apply, what they have learned over the last year to mitigate their own risks (hands / face / space), for the long term. Whether Covid-19 becomes like seasonal influenza, something we live with and manage with an annual vaccine, it certainly won’t be the last we see of it and neither will it be the last pandemic we see.

On 8 June 2020 the UK government initiated quarantine restrictions on incoming travellers. With a few minor, and clearly (?) defined, exceptions everyone arriving in the UK by air, sea or rail, has to self-isolate for 14 days.

In the weeks since ‘lockdown’, during a period of unusually fine weather, 1000 illegal migrants arrived on the shores of the UK by various means – mostly small boats crossing the English Channel. In one day alone, in the week before the new restrictions, 160 arrived. How many arrived undetected is obviously not known.

In the context of quarantine restrictions intended to prevent ‘importation’ of new Covid-19 infections, one has to wonder where, and how, the illegal migrants are being quarantined – for their safety and ours – and how many of them have been tested and proved ‘positive’ for Covid-19?

In recent years there has been a growth in numbers of people (mostly young people) undertaking physical challenges that involve high risk. One of these is ‘Tombstoning’ – the practice of jumping from height, sometimes considerable height, into a body of water.

Over the sunny weekend of 30/31 May, in Dorset (UK), there was an incident involving ‘tombstoning’ which provides a clear metaphor for the UK government’s decision to relax the strictures of ‘lockdown’.

People were frustrated by being confined, at that time for 10 weeks, and the government had signalled that we could have a degree of freedom to go outside. It began by saying, three weeks previously, that we could travel any distance to enjoy exercise, as long as we maintained the prescribed social distancing of 2m while doing it. Predictably, people took that as a green light to go to the ‘seaside’ – in their thousands. Cars streamed to the coast, clogging roads and carparks, disgorging their occupants in confined locations where it was inevitable that ‘social distancing’ would be challenging if not impossible.

Durdle Door, in Dorset, is an iconic and beautiful location where an enclosed shallow bay features a natural arch over the water. It is, or should be, self-evident that an enclosed bay surround by cliffs will have limited access, and the limited space on the beach will be influenced by the fall and rise of the tide. Apparently not. Many hundreds of people arrived and spread themselves on the beach. Amongst them were three who decided it was a good idea to test their bravery by climbing up the cliff, over the arch of the ‘door’, and ‘tombstone’ 70 feet into the shallow water, encouraged by the onlooking crowd shouting “Jump, Jump”. They were all seriously injured and had to be airlifted from the beach to hospital, although it is questionable anyway whether land ambulances would have been able to get anywhere near on the clogged roads. To make room for 2 helicopters to land safely, hundreds of people were compressed into a small space, destroying what remained of any potential social distancing, and were eventually evacuated from the beach up the single access path in a massive ‘crocodile’ file. In this case, amongst the unknowable number of already infected people on the beach, any one or all three of the jumpers might have Covid-19, presenting risk to their rescuers and medics, not to mention that flying helicopters into that location is not entirely risk-free either.

This event is where my case for ‘metaphor’ comes in. Over a fairly short time frame UK governments (there are 4 devolved administrations) have decided to shout “Jump, Jump” while we contemplate tombstoning off a lockdown cliff. In the face of conflicting (and in some cases absent) evidence and scientific advice, we are being told we can come out of lockdown but, explicitly, to do our own assessment of risk! The problem with this is that the assessment of risk, in relation to Covid-19, remains, as it has been all along, selfishly focussed on not catching the disease rather than not spreading it. One thing the scientists are agreed on is that we need a robust, fully functional, ‘track and trace’ system to pick up, and isolate, outbreaks of disease. We have seen the value of this in other countries where they had systems for, and experience of, population scale testing and tracking in pandemics. To be robust and fully functional it needs to have adequate capacity, both for carrying out tests and analysing the results, and critically that means speed because outbreaks must be stopped quickly or they rapidly get out of control. At present the UK does not have this and, by all accounts, the statistics on tests carried out are suspect. The evidence, or should I say experience, from other countries where they have had a better grip of Covid-19 is that it keeps coming back. Other countries experimenting with coming out of lockdown have low rates of new infection, in the low hundreds at most. Our daily rate of new infections is stubbornly high, apparently around 8000, of which perhaps 25% are actually confirmed by a test. After 10 weeks of lockdown, which has limited movement and contact, one has to ask why? What is driving community transmission? I have my own theory, which is asymptomatic spread. Asymptomatic infectees will not be picked up by track and trace, or other existing testing, because they fundamentally require self-reporting of symptoms. Those contacted by ‘track and trace’, as having been in contact with someone who is confirmed (by another test) as infected, will be asked to isolate. However, though they may also be infected they may not have, or go on to develop, symptoms. In fact they may be the person who unknowingly gave the infection to the reporting person in the first place!

The science around modality of spread, of viability of deposited virus, of viable infectivity in a person after infection, of any acquired immunity and persistence of immunity, is weak. This brings me back to my metaphor. In a country where some seem only too ready to accept the government’s encouragement to “jump”, while applying their own assessment of risk to them, I fear we are all tombstoning to potential disaster with them.

I am not a scientist, so what I write here has to be viewed as the product of an interested, but inexpert, mind.

I have been repeatedly struck by the similarity between the Hans Christian Anderson fairy tale, The Emperor’s New Clothes, and the UK Government’s response to the Covid-19 pandemic.

For any reader not familiar with the story, a pair of con-men tailors persuade an Emperor that they could make him a magic suit of clothes. The suit would be so special that only superior citizens could see and appreciate it. Nobody would admit to being inferior, including the Emperor himself, so nobody would say that the suit was imaginary: it didn’t exist. Eventually it takes a small child to puncture the community conspiracy and call out that the Emperor is naked. I am calling out. I am saying our political leaders, and the scientists they defer to, are naked: they don’t know what to do (or are unable to do what they need to do) even though they profess to know.

It seems to me that the UK, and UK media in particular, is bewitched by the 2020 Covid-19 ‘smoke and mirrors’ version in which they, and we, are told to believe in something patently untrue because they, and we, are afraid of looking stupid in the face of “the Science”. We, the mere mortal citizens, cannot understand the complexity of this pandemic and are afraid to ask difficult questions in case we seem ill-educated.

This is plainly nonsense. First of all our media are replete with clever, well educated, people. Moreover we, the populace, are not generally ill-educated and seem blessed with something which seems singularly lacking in the narowly focussed Government science community and the Government itself: common sense.

Every day, and I mean every day, a UK Government minister hosts a so-called press conference from Downing Street in which ‘slides’ of graphs, updated from the day before, are presented by a ‘scientist’ to illustrate progress in the fight against the virus. This presentation is followed by questions from the media. Recently, presumably in an effort to engage the public in an illusion of transparent democracy, two questions are first taken from members of the public. The Government claims these questions are ‘unseen’ but it is evidently untrue because you can see the ministers, in particular, consulting notes when speaking in response to the questions. I will try to ‘pick over’ some of the anomalies that arise from these questions and answers.

Being Led by the Science

One of the advantages of saying you are following the science is that you can blame the scientists if it all goes wrong. It’s the job of Government, both as leaders of the country and as employers of the scientists, to test the scientists, or at least ask them hard questions, however ‘daft’ they may seem. It has been marked, really marked, how often the scientists speaking at the daily press conference say something like “it’s too early to say, it’s difficult to draw conclusions from the data, we’ll know what happened when it’s all over”. In short, they often say “we don’t know”, so how can anyone follow that lead?

The charts shown to the public display, and invite, international comparisons and yet the scientists say “it’s very difficult to make comparisons because the data across countries is not recorded consistently.” If it’s difficult (or even meaningless) to draw comparisons why do they show these charts?

Testing

The Government’s approach has, like the science, been ‘behind the curve’. At the outset of the epidemic, before it became an official pandemic, the World Health Organisation advised “Test, Test, Test”. The UK did not. Those countries that did, seem to have had a different level of transmission. Some countries imposed travel restrictions, quarantine and scanning for elevated temperature in arrivees. The UK did not. Some countries were very quick to impose lockdown, the UK was not. Worldwide, but especially in S.E. Asia where they had both a culture of routinely wearing facemasks when ill, but also experience of epidemics of respiratory diseases like SARS and MERS, the community response was immediate and effective. The UK’s was not. In the UK our limited capacity for testing outside of hospital was initially focussed on getting medics and carers back to work because the medical workforce was under pressure. Once the decision was taken to increase testing (and I think this decision was forced by public pressure) the figures of tests undertaken became a politically, not medically, important key performance indicator and therefore had to be presented in a ‘managed’ way. The results from those tests, especially in hospitals, became a key indicator in the progress of the disease through the population and of the prevalence of the disease in the country as a whole. It emerged very early on that there was a range of severity: the majority of infected people would experience only mild symptoms and some would have no symptoms at all. A smaller number would need hospitalisation, about half of those would need intesive care, and of those requiring the highest level of hospital intervention (sedation and ventilation) a significant number of those would die. These numbers became key indicatiors of the progress of the disease, and of healthcare performance through mortality rates.

What nobody seems to have grasped (or been prepared to call out) is that testing, any kind of testing in the sick population, that is to say those persons presenting in care settings and exhibiting symptoms, is only confirming what is already suspected. Two cohorts of the population were missed by this approach to testing, and therefore any measurement of population prevalence is distorted. First, those people with ‘mild to moderate’ symptoms were (and still are) required to self-isolate at home. Until the proposal to use an ‘App’, see below, they were not counted as cases. They were not tested (unless as part of the belated testing of key workers), they were not confirmed cases of Covid-19 and their contacts were not traced. Secondly, those people with no symptoms at all, or misidentified as ‘just having a cold or hayfever’ were, and still are, free to circulate in the population to potentially shed and spreading the virus: the Typhoid Mary effect.

Laterly, in May 2020, the Government has started a limited trial of an ‘App’, a technological solution to tracking and tracing outbreaks of disease. If deemed successful it will be rolled out across the UK. People who use this ‘App’ will be asked to monitor their state of health and, if exhibiting symptoms, report illness. The ‘App’ will then inform their ‘contacts’ who will be advised (advised!) to self-isolate and so break the chain of transmission. It seems to me there is an obvious, and fatal, flaw in the logic of this approach, and that is the Typhoid Mary effect. Track and Trace only works on those people who have symptoms: officially at least 30% of the infected population are asymptomatic.

Chasing the ‘R’ Number

The distortion of the real, natural, level of community transmission of Covid-19, and therefore pursuit of the magic ‘R’ number, has been profound.

The ‘R’ number is the reproduction rate, the rate by which one infected person passes an infection on to others: its ‘natural’ infectivity in a population with no immunity. An ‘R’ of 1 means one person will infect one other and the infection rate is stable, while anything above 1 means an exponential growth of infection. The ‘R’ of normal ‘flu is about 15 – it’s highly infectious. The natural ‘R’ of Covid-19 is said to be 3. There is no way to change the natural infectivity, the ‘R’, of Covid-19. Until we can develop a vaccine, all we can do is reduce its opportunity to make people sick by hygiene measures and, crucially, keeping people away from each other. What we have managed to achieve, with extreme restrictions and the wrecking of our economy, is an un-natural ‘R’ number hovering between 0.5 and 0.9. Clearly, then, something is going on which is sustaining new infections. The UK government is saying the locus is now Care Homes. I really struggle with the logic of this; Care Homes are, more-or-less, ‘closed’ communties. Once the problem was identified, even with mass mortality as we have had, how does that drive infection in the wider population? I suggest that it is the reservoir of undiagnosed, untested, and asymptomatic infection. That being the case, the relaxation of the measures to keep people apart will inevitably result in a resurgence of the disease.

What the UK government seems to have decided is that the economy must be restarted, and has embarked on an experiment in which we are the guinea pigs, to see what happens if we let the reins slacken. The government says that ‘lockdown’ can be reinstated if this happens, but I suggest this is unrealistic: once the freedom genie is out of the bottle there is no way the public can be persuaded to put it back and comply with the measures in the way they have, broadly, until now. I don’t doubt that behavioural science is informing some of the epidemiology, but we have already seen the extent of wilful disregard for lockdown measures, as well as plain misunderstanding. The UK Prime Minister has pleaded for “good British common sense” to apply: in effect this sounds like “it’s too complicated to explain or advise about, even for me, so just do whatever you think is right”. Meanwhile he, in jocular filmed visits to hospitals, has demonstrated that by not washing his hands thoroughly he thinks it’s a bit un-necessary.

Epidemiology

We know that the first widescale outbreak of what became labelled Covid -19 was identified in a Chinese city of 11 million people called Wuhan, in the province of Hubei. As far as we know it was noticed in December but officially denied. Travel in and around China continued, and critically beyond China’s borders. The first confirmed cases in the UK were two travelling Chinese nationals who had arrived in Newcastle, but blaming China has become a politically convenient distraction. What has only recently become general knowledge is that cases appeared in Europe in December, before it was officially reported in Wuhan. That means it was circulating more widely there (and elsewhere) for longer than was suspected, and therefore maybe even calls into question the location of the original outbreak. Moreover, DNA-based research has shown that the origin of disease in other parts of Europe was significantly driven from the UK. We know the virus is highly infectious, and we now know it has been mutating: the strain that subsequently arrived in the West coast of the USA, from Asia, was different from that which over-ran New York that came via Europe (and therefore the UK).

Virology

When we bagan to hear about a virus outbreak, we were told “Catch it, Kill it, Bin It” – and wash your hands thoroughly and often. We were told this was because the virus was spread by “droplets” getting from an infected person to someone else, directly by coughing or sneezing, or indirectly by the droplets landing on a surface and then being picked up by them and transferred to the mucus membranes of a face / mouth / eyes. Initially we were told that you had to be in close contact, face-to-face, for 10 to 15 minutes, and to stay more than 1.5 metres away. The obvious question then was how long the deposited virus ‘droplet’ remained viable on a surface, and it wasn’t (and still isn’t) clearly answered. Then we got the 2m ‘social distancing’ rule, but evidence emerged that droplets were spread over varied distances in an ‘aerosol’ according to the environment, inside or out, by someone with virus on their hands touching something, and what people were doing like exerting exercise, which called into question the adequacy of 2m as a safe distance. Now we are advised to stand side by side, not facing each other, and as near as 1m if using “mitigation” measures. We have also now found that the virus can remain viable on clothing for several hours and that we should wash our clothes frequently, which makes a bit of a nonsense of the original advice to sneeze or cough into our elbow and shaking hands by ‘touching’ elbows.

The fact (and I use that word with caution) is that the virology, based in laboratories, cannot keep pace with the developing ‘field’ epidemiology with sufficient speed. That is to say that what’s happening in the epidemiological ‘reality’ is outstripping laboratory science’s ability to answer the new questions raised by changes in the experience on the ground. And so those of us without specialist expertise are watching the news from other parts of the world to see what they are doing, and how effective it has seemed to be, and applying our own common-sense response. Some people (me included) ordered facemasks, gloves and hand sanitizer, and began to adapt our behviours in and outside the home, even before a pandemic was declared. I mentioned the question of facemasks earlier in this piece, and of all the visible measures that various countries could have taken, the wearing (or not) of facemasks has been an obvious point of difference. Facemasks are routinely worn in a medical setting for two reasons, the principal one of which is not contaminating the patient by breathing on them. The secondary reason, except in specific cases, is protecting the clinician from any bacteria the patient may pass on to them. The specific exception is where the risk from the patient is bacteria (or viruses) transmitted by them in an aerosol spray – in which case a high performance, moisture resistant, mask is required (to standard N95 or higher).

The UK government, and its scientific advisors, consistently said that masks had no benefit in protecting the wearer, in fact suggesting they risked the health of the wearer because they would contaminate themselves putting them on or taking them off. This inexplicably ignored that the principal benefit they admitted was in reducing the risk of an infected person passing the virus on, and reducing transmission was the key objective of the lockdown! For weeks the government steadfastly refused to recommend general wearing of masks, even in the face of a growing public clamour, and this week (11 May) has only grudgingly “advised” (not mandated) the use of masks, as long as they are home made, saying that medical grade, or style, masks were inappropriate and should be kept for clinical settings because clinicians, nurses, carers, paramedics etc., need them for their protection. One has to ask if a mask protects a paramedic, why doesn’t it protect a member of the general public? Of course, all of this has to be seen in the context of a massive failure to hold stocks of, or procure, adequate Personal Protective Equipment (PPE), of which masks are but one example. Almost uniquely in the “western” world, the UK has a universal and centralised healthcare service: the NHS. However, successive politically Conservative governments have sought to privatise the service and so the delivery of healthcare has been incrementally fragmented under the cloak of “efficiency improvements”, and responsibility devolved to area Care ‘Trusts’. The UK government was warned a year before the outbreak that we were unprepared for a pandemic and that central stocks of essential equipment were low. The government initially sought to blame the Trusts for mismanaging their ordering and stockpiling of PPE, ignoring the fact that the NHS had been systematically ‘bled’ of funding in the wake of the 2008 world financial crash. Then they sought to blame the public, who had bought their own PPE, for using up finite resources. Once they realised this blame game was not going to work with the public, their failure to deliver PPE to the front line medics, and care homes, resulted in the government giving daily scores of “items of PPE delivered” as fatuous as counting an individual glove as an item. The government clearly could not recommend the public to wear masks when there weren’t enough for doctors, nurses and carers. Now we know there is mounting evidence that facemasks do, indeed, protect the wearer (and in early June both the WHO and our UK government recommended widespread us of “face coverings” and specifically medical grade masks for the over 60s). By early July the WHO raised the possibility of airborne transmission, which suggests more widespread use of facemasks will be required.

What Next

We have no vaccine. We may never get a vaccine. If we do it may need to be redeveloped every year like the ‘normal’ seasonal ‘flu vaccine because the Coronavirus naturally mutates. There is some evidence that some infected persons have developed antibodies and therefore some immunity. Our NHS is experimenting with infusing sick people with plasma drawn from previously infected people. We do not know if this immune response is consistent across all sections of all populations, and even if it is we do not know how durable the immunity is. Without an effective vaccine we are going to have to live with, i.e. adapt our ways of life, the presence of Covid-19 (or Covid-20/21/22 etc.) for the long term and depend on improving therapeutic treatments to help us survive infection – if not knowing very much at all doesn’t kill us first.