Over the weekend I was challenged to a video debate about public health policy during the pandemic. I said that for various reasons it would be easier for me if it was conducted in writing.

It was agreed that Bruce Wallace and I would write 2000 word opening statements of our opposing views.

The opening statements are below.

Opening statement by Bruce Wallace:

Climate of Fear

As the infections and deaths from COVID-19 begin to subside perhaps it is time to take stock?

It is historically unprecedented to try to combat a pandemic by quarantining the healthy instead of the sick. Such action needed the Fear Card. The MSM have obliged with 24/7 COVID-19 coverage in the most lurid and horrific detail. So effective has this propaganda campaign been that an LSE poll found that 84 percent of the population supported lock-down to avoid a national catastrophe. The slogan Stay at Home, Protect the NHS, Save Lives became almost universally believed like an article of faith.

Professor Robert Dingwall who sits on the Government’s New and Emerging Respiratory Virus Threats Advisory Group (Nervtag) that feeds into its Scientific Advisory Group (SAGE) stated:

We have this very strong message which has effectively terrorised the population into believing that this is a disease that is going to kill you. And mostly, it isn’t.

Eighty per cent of people who get this infection will never need to go near a hospital. The ones who do go into hospital because they are quite seriously ill, most of them will come out alive-even those who go into intensive care.

We have completely lost sight of that in the obsession with deaths, the human interest stories about deaths, the international comparisons about death rates, the opportunity for intrepid television journalists to put on lots of PPE and go into high tech where people are seriously ill.

All of this helps to create a climate of fear, and I am not surprised in a sense that the Government might take a cautious approach to try to unlock the lockdown, simply because they would really be nervous that if they pushed it too quickly it would be like giving a party and nobody came.

Having played the Fear Card and whipped up unprecedented hysteria the government is finding just how difficult it is bring people back down to earth. The latest farce being reluctance to support the opening of schools until it is “safe”.

Interestingly the risk of COVID to children is practically zero and in its pre-lockdown assessment SAGE found that closing British schools would have a very limited impact on reducing transmission of the virus. Closing schools in the first place was unnecessary and an over the top reaction from the (we follow the science) government under incessant media pressure. Now children are expected to return to a dystopian regime of social distancing and PPE.

bruce1

Not an Extraordinary Virus

Doctor John Lee, once a distinguished NHS pathologist, has called for an end to lock-down . I summarise his arguments below with my own interpolations.

Determining exactly how many have died from the virus in the UK is problematic. Differences in data collection, as well as delays in death registrations, contribute to the uncertainty. The only way to identify if somebody has died from COVID-19 is through autopsy. This is impossible given everybody who has died with suspected COVID-19 in the UK has been cremated.

There is a distinction to be made between having died with COVID-19 as opposed to having died of it. The actual death toll could be an overestimate or an underestimate. Nobody really knows. We never know the precise figure of fatalities from any pandemic.

Lee conceded that the only data that we can be clear about are the raw number of deaths. In 2015 there were 28,330 deaths from seasonal flu. He assumes that there could be approximately 40,000 COVID deaths. That sounds horrific but our total all cause mortality is below the number of winter deaths in 1998,1999 and 2014. It is also half of the 80,000 deaths suffered in the 1968 Hong Kong Flu pandemic (no lock-down for that one). The death toll is in the same ballpark as seasonal flu and a disease we can live with, not something extraordinary that requires draconian emergency measures.

bruce2

World deaths from COVID-19 of roughly 322,861 might spook those normally uninterested in disease but this is a mere trifle compared to the major global killers. It would hardly register on the graph of the 58 million global deaths last year even if it were multiplied seven-fold. By comparison seasonal flu kills up to 650,00 annually, Typhoid fever 160,000, Cholera 140,000, Malaria 620,000. In 2018 an antibiotic resistant tuberculosis killed 1,500,000. None of this caused a virtual global lock-down because those killed were largely in the post-colonial world.

The main group that COVID-19 affects are the elderly and those with serious underlying health conditions (comorbidities). To say that this is uncaring or callous is fallacious. It merely acknowledges a simple fact of life. 90 percent of those who die will have serious health conditions or be nearing the end of their lives and are more vulnerable to a novel infection. Hence why many of those who have died had their serious underlying conditions exacerbated by the virus and their deaths were from multiple causes. Even if COVID- 19 was put down as the cause on their death certificate. Tens of thousands of older people die every year from seasonal flu without anybody batting an eye. It is death from natural causes.

Has Lock-Down Worked?

The basis of the current policy is the flawed models of infection that the government relied upon from Professor Neil Ferguson from Imperial College London. His computer modelling predicted an 80 percent infection rate and a death rate of up to 3.5 percent. That would mean a lot of deaths. He projected it as being as high as 500,000. As there has been no large-scale community testing the actual infection rate, or “R rate”, isn’t known and can only be estimated on the basis of limited data. It is more likely much lower than 80 percent and probably nearer 17 percent. Ferguson’s model was clearly a gross overestimation. It did panic the government into the lock-down fearing that the NHS would be overwhelmed and result in a public health catastrophe.

Do we know if lock-down has worked? No as any direct evidence of its effectiveness is minimal and based on computer modelling. Other countries with very different measures have similar virus curves. It’s easy to make plausible arguments that lock-down “must” be slowing the spread of the virus but Sweden’s voluntary social distancing measures appear equally effective and at much lower cost.

Were the variation in mortality due to the measures taken by governments we would expect lock-down to mean lower death rates and visa versa. Yet there is no such pattern. For instance:

  • The US has 4 percent of the world population, roughly 25 percent of the reported deaths (depending on how you count). Philippines, with a less impressive healthcare system, and more variable “lock-downs,” had 20 times less deaths per capita.
  • Taiwan, 24 million people, 7 deaths, 0.3 per million, no lock-downs.
  • Belgium and Sweden, same population, both with issues with nursing home deaths. Sweden’s deaths are roughly 322 per million with very mild largely voluntary lock-down, Belgium’s with an extremely strict lock-down, 751 per million.
  • Japan with a functioning economy throughout, focused, short-term restrictions only, death rate is 5 per million.
  • Iceland, no lock down, 29 per million COVID deaths.
  • Ethiopia, no lock-down, fatalities 0.04 per million.
  • Vietnam, targeted brief lock-downs, 0 fatalities.

Were strict lock-downs working how can such wide disparities be explained? The only logical answer is that the virus is affecting different countries in different ways irrespective of government measures.

Moreover, the lockdown is costing lives. The economic and direct health costs of lock-down are enormous but there has also been massive disruption of health care for non-COVID conditions (cancer and elective surgery for example) that are having immediate, but also delayed, effects. Hospital A&E visits have dropped by 57 percent and a lot of people are dying at home, not from the virus, but from untreated health conditions. Economic downturn itself is a direct cause of ill health. The lock-down is causing the biggest economic downturn in three hundred years.

Not Sustainable

Neither is lockdown sustainable. COVID cannot be eradicated and we will need to open society at some point so lives saved now may well be lost later. Our own immune systems have been honed by millions of years of evolution to cope with viral threats. They are the only way to survive in a world full of viral pathogens. Countries now pleased with low infection and death rates will have to face the virus in the future or become totally isolated. No country ever improved the health of its population by making itself poorer and lockdown is impairing our ability to live with the virus while not changing the long game.

Lock-down also harms those directly affected by COVID, primarily the elderly. Either through social isolation or failure in receiving health care this lockdown is having a terrible impact on the lives of the healthy old. Meanwhile it is harming people who will be largely unaffected by COVID. People under 65 and especially those under 50, will be no more inconvenienced by this disease than by the common cold. This is the most productive part of the population who support everybody else. Why is it more effective to place them in quarantine instead of those at higher risk? Lost education, lost job opportunities and lost livelihoods cannot necessarily be made good.

NHS Protected

The NHS has not been overwhelmed and is unlikely to be. Many hospitals are half empty and the emergency hospitals were never used. This fear cannot be used to justify the continuation of the lock-down and the government’s rationale for the lock-down is becoming more and more incoherent .

It does raise questions about the way our NHS dropped practically all other treatments to focus almost exclusively on COVID on orders from government and NHS managers. The doctors and nurses are rightly seen as heroes but not necessarily NHS managers who cleared wards of sick elderly patients seeding a COVID holocaust in our care homes.

This raises moral questions. Why should patients with one disease receive treatment and take priority over others? Doctor Lee estimates that there have been at least 10,000 non-COVID excess deaths so far in 2020. These are people who have died having not sought treatment and avoided hospitals (heart attacks, cancers and strokes). Professor Sir David Spiegelhalter, a statistical adviser to the government, described these tragedies on the Andrew Marr show on May 9 as “collateral deaths” caused by the lock-down. It galls me that there is mass virtue signalling from lock-down fanatics about “saving lives” when thousands are dying because of it. Tragic stories are emerging of cancer sufferers having their lives cut short as their treatment has been delayed.

Evolutionary View

An evolutionary view would suggest that this virus, like all others, is likely to change quickly with less virulent forms becoming dominant. Lock-down could potentially slow down this beneficial tendency. This means that non symptomatic people spreading the virus is a good thing which would help to make the disease milder and less virulent. And this could even be a contributory factor to the flattening viral curve already.

The sooner we lift the lockdown the better. It implies that the peak of the virus that was reached in early April is likely to have been as bad as it will get. In future the virus will come into equilibrium with the population as wider immunity combines with predominantly milder forms to cause a lower death rate. This will fluctuate very much like seasonal flu which is another serious disease we live all with.

Swedish Advice

Sweden didn’t lock down although it stopped mass gatherings of over 50 but schools, shops, bars, restaurants and businesses didn’t close. It has taken precautionary measures but these are voluntary and Swedes are following government health advice. This approached was even hailed as “a model” by the World Health Organisation (“WHO praises Sweden for coronavirus response resisting shutdown” Washington Examiner April 29).

Swedish epidemiologist Professor Johan Gieseke wrote a letter to the Lancet on May 5 titled The Invisible Pandemic. He stated:

It has become clear that a hard lockdown does not protect old and frail people living in care homes-a population the lockdown was designed to protect.

Neither does it decrease mortality from COVID-19, which is evident when comparing the UK’s experience with that of other European countries.

And:

These facts have led me to the following conclusions. Everyone will be exposed to severe acute respiratory syndrome coronavirus 2, and most people will become infected. COVID-19 is spreading like wildfire in all countries, but we do not see itit almost always spreads from younger people with no or weak symptoms to other people who will also have mild symptoms. This is the real pandemic, but it goes on beneath the surface, and is probably at its peak now in many European countries. There is very little we can do to prevent this spread: a lockdown might delay severe cases for a while, but once restrictions are eased, cases will reappear. I expect that when we count the number of deaths from COVID-19 in each country 1 year from now, the figures will be similar, regardless of measures taken.

Indeed! This lock-down will go down as the greatest example of collective self-harm in our nation’s history. It must end as soon as possible before more damage is done. Not just enormous economic harm but widespread harm to our own collective health. Far from achieving its stated aim it has failed to stop the death toll or protect the vulnerable. It will have been all for nothing.

Opening Statement Paul Cockshott

In defence of the COVID lockdown

There is no doubt that the best option for a country is to use border controls, tracking tracing an isolation to prevent COVID-19 even starting widespread community transmission. But if that fails, Lockdowns are needed. I have been challenged to debate by an opponent of lockdowns for the Covid-19 crisis. I will be arguing for a policy in which lockdowns are a key element. It will cover the following points:

  1. First I will show that COVID-19 is a serious danger.
  2. Next I will show that the herd immunity policy that the Tories initially advocated would lead to catastrophic numbers of dead in any country that followed it.
  3. I will then review the evidence for the success of lockdowns.
  4. Finally I will outline what should be the long term policy of any government trying to deal with the crisis.

How fatal is COVID-19

As of the end of March the best estimate of fatality rates was around 1%. An article in The Lancet reported :

A unique situation has arisen for quite an accurate estimate of the CFR of COVID-19. Among individuals onboard the Diamond Princess cruise ship, data on the denominator are fairly robust. The outbreak of COVID-19 led passengers to be quarantined between Jan 20, and Feb 29, 2020. This scenario provided a population living in a defined territory without most other confounders, such as imported cases, defaulters of screening, or lack of testing capability. 3711 passengers and crew were on board, of whom 705 became sick and tested positive for COVID-19 and seven died, giving a CFR of 0·99%.

 

This figure of 1% was based on 7 deaths, so was subject to considerable random noise. It could have been too low or too high. It is necessary to have larger samples to be more confident.

More data comes from the epidemics in Italy and New York. For instance the province of Bergamo has had a population death rate of 0.58%, [Modi et al May 2020] .  The caveat to this lower bound is that we lack data on what percentage of the Bergamo population were infected.

The infection death rate has to be higher than the population death rate, only part of the population will have been infected. Modi et al estimate that the lower bound on the infection death rate from the Lombardy data is 0.61%, the actual rate is likely to be higher.

 

More accurate data has become available from a  serology survey in New York. A summary is given on the Worldometer site.

 

 12.3% of the population in the state had COVID-19 antibodies as of May 1, 2020.  This percentage would indicate that 1,671,351 people infected with SARS-CoV-2 as of May 1. Total of actual deaths: 13,156 confirmed + 5,126 probable + 5,148 additional excess deaths calculated by CDC = 23,430 actual COVID-19 deaths as of May 1, 2020 in New York City. The CDC added in deaths of those who died outside of hospital settings. 

 

This gives an infection death rate of 1.4%.

 

Allow for the fact that the disease takes some 3 weeks to kill people, and allow 1 week for antibodies to appear, this implies we need to look for total deaths in New York on or around the 14 May, to estimate fatality from those who had been infected by  May 1. Below I present a calculation assuming the same ratios between hospital and non hospital deaths.
paul1

So this is somewhat higher and is still conservative, since not all people infected on the 1 May who will not recover will have died by the 13th May.

 

We have a range of estimates of the death rate going from an absolute lower limit of 0.61% for Italy to 1.68 for New York, with the cruise line figure of 1% sitting in the middle.

The New York data is arguably more reliable than the Bergamo data, based as it is on larger samples and being backed by random sampling of the population for antibodies. 

What would be the result of Boris’s Herd Immunity policy?

In early March the UK government dropped its policy of attempting to contain the spread of COVID-19 and instead decided that the country should as the PM put it ‘take it on the chin’ and wait to acquire ‘herd immunity’. It is widely speculated that Cummings was behind this.

 

This policy lasted only a week or two before the rapidly rising case numbers coupled with a study from Niel Fergusons’s group indicated that this policy would involve at least a quarter of a million dead.

 

There has been subsequent criticism of Ferguson both because of his personal sexual life and because of bugs found in the Imperial College code. But even more worrying predictions were made by other academic groups. One does not need sophisticated simulation to calculate that very large numbers of deaths would result from the initial Tory policy.

 

Herd immunity is a concept used to calculate how many people you need to vaccinate to prevent epidemics. It depends on the R value of the disease.

 

The R0 value for COVID-19, the number of people each infected person infects in the absence of public health measures, is estimated to be around 2.5. It is well known in epidemiology that to establish herd immunity you need a proportion of the population equal to 1-(1/R0) to be immune either due to vaccination or recovery from previous infection.

 

For a virus with an R0 of 2.5 that implies at least 60% must be immune.

 

It is easy to understand why. Suppose 60% are immune. If 10 people would each pass the virus on to 2.5 people then they would pass it on to 25 others. If 60% of those 25 were immune, 15 of those who contacted them would be unaffected, leaving 10 new infections. So at a 60% immunity you have a slow burn infection, neither expanding or contracting. At 80% immunity, 10 people would infect only 5 new people so the infection level would halve with each generation of infections.

So this implies that if you want to establish vaccination herd immunity for COVID-19 you need to innoculate well over 60% of the population. You should probably aim for 80%.

But the situation is different in the case of an uncontrolled epidemic. There is no reason to believe that the number infected will stop at 80%. Remember that at 60% each infected person still infects one other. On the day that the UK reached 60% infection level, there would be tens of millions of people who were infectious. If each infected one other, then approaching 90% of the UK could be hit.

So using what we now know about the fatality rate and making the conservative estimate that only 80% would have caught the disease, what would have been the consequences of Cummings’ cunning plan?

 

UK population 66,000,000
Percent infected 80.00%
Number infected 52,800,000
fatality rate 1.68%
Total deaths 888,151

 

The death rate estimate is conservative. If the NHS was overloaded and people could not get oxygen, far less CPAP machines, the death rate would rise to at least the 3% seen in Wuhan under similar circumstances and you could have close to 2 million dead.

From what we now know, the Ferguson estimate was on the low side. Even a regime as cold hearted as the current Tories could not go ahead with such a reckless proposal.

 

That some continue to push this failed Tory idea, now that we know that death rates are even worse than we knew in March is a testimony to the social backwardness imposed by decades of neo-liberalism.

 

Did Lockdown work?

The answer is yes, it certainly does. 

Lockdown was first imposed in China, and what is revealed in the Chinese graphs below is typical of what we see in all nations that impose strict lockdown measures. The following points can be clearly seen:

  1. About a fortnight after lockdown the number of new cases starts to fall. The delay is due to there being about 1 week of incubation period followed by a week of illness before people present to hospital.
  2. The death rate starts to fall after about 3 weeks, since fatalities typically occured a week or more after admission to hospital.
  3. The downslope under lockdown is more gradual, so it takes longer to eliminate the epidemic than it took for it to peak.
  4. If the lockdown is maintained for long enough, community spread of the virus is reduced to near zero.

paul2

Case tracking for China, lockdown imposed Jan 21. Peak on Feb 13 due to figures including those diagnosed by CT scan rather than just by PCR test.

pasted image 0

Covid tracking Deaths per day China 

 

Spain shows a similar general trend. Again about 2 weeks after lockdown on the 15th March, the number of cases per day peaks.paul3

Spain new cases. Lockdown on 15 March.

As in China, the deaths per day peak about a week later.

paul4

Spain daily death totals

So there is no question that lockdown does work to avert a catastrophic explosion of deaths. It is also clear that if applied with sufficient determination for sufficient time it reduces community transmission to near zero. But the time to reduce it to zero depends on how high the peak number of deaths or cases per day was. A country that delayed lockdown has to lockdown for longer. 

 

Long term policy

We know that lockdown can stop an explosive epidemic and can, if maintained reduce community transmission to zero. 

A country that successfully applied the China model was New Zealand which has reduced new cases to zero.

paul5

 

At that point the only new infections that will occur are those introduced from outside the country. 

The implication is that once a country has stopped domestic transmission it must close its borders, either totally, or at least impose very strict quarantine on those entering – quarantine in supervised isolation hostels rather than letting people travel home unsupervised.

Countries that have eliminated transmission can open up travel to other countries that are virus free, but they have to block free movement from any country in which the virus is still present.

 

Once a vaccine becomes available, and once a country has vaccinated a large portion of its population then travel restrictions could be lifted.

 

There is a high probability that a vaccine will be developed. 

It is objected that no vaccine has previously been released for other corona viruses. But for those that cause minor colds there is no motivation to develop a vaccine. For SARS serious attempts were made and candidate vaccines were developed, but funding ran out once public health measures blocked the epidemic.  As of 15 May the WHO listed 8 vaccines for COVID-19 undergoing clinical trials. 110 others are undergoing pre-clinical trials.

The huge number of candidate vaccines reflects the big advances in biotech over the last decade. It is now possible to directly synthesise vaccines from information about the RNA of the virus. 

For example the Moderna RNA vaccine prepared this way, one of the first tested, has already demonstrated that it produces serum antibody levels as high as those seen in serum from convalescent patients that has been used in treatment.

Should a vaccine be developed, then the government of any state that followed the herd immunity strategy, and in consequence had of the order of 1% of its population die, will be seen to have squandered those lives on a fool’s errand.

Of course it is possible, albeit unlikely, that none of the 118 vaccines will work. But in that case we will see a permanent division of the world into pariah states which failed to suppress transmission and those, mainly in Asia, but including some elsewhere, who have eliminated it. Those in the Pariah states will have very limited travel opportunities and will face great obstacles in international commerce.