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Tuesday, 15 December 2020

Self-isolating for 10 days in Birmingham after returning from Greece

Waiting at Corfu Kapodistria Airport for a flight to Athens
At Corfu Kapodistria waiting for a flight to Athens

Over the better part of 2020 I've been able to access more information about the COVID-19 pandemic than has ever been available to any but experts about a pandemic.  Making sense of this information, that comes on the internet via tweets, emails, facebook, podcasts, radio, scheduled TV (remember that?), vlogs and many websites with access to a plethora of peer-reviewed research, is informative, fascinating, vexing and confusing. T S Eliot suggested in the 1930s - 'we are too conscious and conscious of too much'. Lin and I talk to each other, to friends and strangers and of course we experience directly the effects of government policy - in our case in the UK, in Italy and Greece and back in the UK where, having completed our Passenger Location Form, we are confined to our Birmingham home for 14 days, reduced a few days later to 10
Self-isolating at home in England warmed by wood I sawed and split in the summer

For my records I've selected two open letters sent, two and half months ago, to our Chief Medical Officers (CMOs) and, in one case, also to the Prime Minister and the Chancellor - though they've no doubt been advised on both. I can envisage presenting these letters to students of government policy-making and asking them to brief an imagined cabinet on the weight to be placed on either, or neither. I'd also remind the students of the global salad of impugned motives and ad hominem rudery directed at the signatories of these letters and their recipients. Scientific debate was ever thus. I was taught that long ago. I thought science revealed the truth. No. Scientists arrive at the best hypotheses to fit the available data. They defend these hypotheses against other scientists, themselves included. COVID-19 and the world wide web has allowed the scientific process to occur on a global stage with limitless audience participation.

Here's the first letter:

Covid-19: An open letter to the UK’s chief medical officers expressing 'concern about a second wave of covid-19'

Professor Chris Whitty; CMO, England
Dr Frank Atherton; CMO, WalesDr Gregor Ian Smith; CMO, Scotland
Dr Michael McBride; CMO, Northern Ireland
Professor Patrick Vallance; Chief Scientific Adviser

21st September 2020

Dear CMOs 

We write to express our grave concern about the emerging second wave of covid-19. Based on our public health experience and our understanding of the SARS-CoV-2 virus, we ask you to note the following: 

1. We strongly support your continuing efforts to suppress the virus across the entire population, rather than adopt a policy of segmentation or shielding the vulnerable until “herd immunity” has developed. This is because:

a) While covid-19 has different incidence and outcome in different groups, deaths have occurred in all age, gender and racial/ethnic groups and in people with no pre-existing medical conditions. Long Covid (symptoms extending for weeks or months after covid-19) is a debilitating disease affecting tens of thousands of people in UK, and can occur in previously young and healthy individuals.

b) Society is an open system. To cut a cohort of “vulnerable” people off from “non-vulnerable” or “less vulnerable” is likely to prove practically impossible, especially for disadvantaged groups (e.g. those living in cramped housing and multi-generational households). Many grandparents are looking after children sent home from school while parents are at work.

c) The goal of “herd immunity” rests on the unproven assumption that re-infection will not occur. We simply do not know whether immunity will wane over months or years in those who have had covid-19.

d) Despite claims to the contrary from some quarters, there are no examples of a segmentation-and-shielding policy having worked in any country. Notwithstanding our opposition to a policy of segmentation-and-shielding, we strongly support measures that will provide additional protection to those in care homes and other vulnerable groups.

2. We share the desire of many citizens to return to “normality”. However, we believe that the pandemic is following complex system dynamics and will be best controlled by adaptive measures which respond to the day-to-day and week-to-week changes in cases. “Normality” is likely to be a compromise for some time to come. We will need to balance suppressing the virus with minimising restrictions and impacts on economy and society. This is the balance that every country is trying to find—and every country is having to make trade-offs. This might mean moving flexibly between (say) 90% normality and 60% normality. We believe that rather than absolute measures (lockdown or release), we should take a more relativistic approach of more relaxation/more stringency depending on control of the virus.

3. Controlling the virus and re-starting the economy are linked objectives; achieving the former will catalyse the latter.  Conversely, even if policies to promote economic recovery which cut across public health objectives appear successful in the short term, they may be detrimental in the long term.

4. As evidence accumulates for airborne transmission of the SARS-CoV-2 virus, measures which would help control the virus while also promoting economic recovery include mandating face coverings in crowded indoor spaces, improving ventilation (especially of schools and workplaces), continuing to require social distancing, and continuing to discourage large indoor gatherings, especially when vocalisation is involved. With measures like these, much of society will be able to function effectively while keeping the risk of transmission relatively low.

5. As we move beyond the acute phase of the pandemic, it is important to restore routine medical appointments (e.g. for long-term condition review and patient concerns that may indicate new cancers). We believe that a combination of remote appointments (online, phone and video) plus face-to-face appointments with appropriate personal protective equipment will allow this to happen safely. We recommend a communication campaign to inform the public that the NHS is now open for most routine business.

6. In a complex system, we should not expect to see a simple, linear and statistically significant relationship between any specific policy intervention and a particular desired outcome. Rather, several different policy measures may each contribute to controlling the virus in ways that require complex analytic tools and rich case explanations to elucidate.

7. While it is always helpful to have more data and more evidence, we caution that in this complex and fast-moving pandemic, certainty is likely to remain elusive. “Facts” will be differently valued and differently interpreted by different experts and different interest groups. A research finding that is declared “best evidence” or “robust evidence” by one expert will be considered marginal or flawed by another expert. It is more important than ever to consider multiple perspectives on the issues and encourage interdisciplinary debate and peer review. While government must continue to support research, some decisions—as you will be well aware—will need to be made pragmatically in the face of uncertainty.  

We thank you for your continuing efforts to get us through the pandemic. 

Trisha Greenhalgh, Professor of Primary Care Health Sciences, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Dr Nisreen A Alwan, Associate Professor in Public Health, University of Southampton.
Professor Debby Bogaert, Professor of Paediatric University of Edinburgh.
Professor Sir Harry Burns KBE, University of Strathclyde and Past Chief Medical Officer, Scotland.
Professor KK Cheng, Professor of Public Health and Primary Care, University of Birmingham.
Dr Tim Colbourn, Associate Professor of Global Health Epidemiology and Evaluation, UCL Institute for Global Health.
Dr Gwenetta Curry, Lecturer of Race, Ethnicity, and Health, College of Medicine and Veterinary Medicine, University of Edinburgh.
Dr Genevie Fernandes, Research Fellow, University of Edinburgh and Action Team Member, Royal Society's DELVE Initiative.
Dr Ines Hassan, Senior Policy Researcher, Global Health Governance Programme, University of Edinburgh.
Professor David Hunter, Richard Doll Professor of Epidemiology and Medicine, University of Oxford.
Professor Martin McKee, Professor of European Public Health, London School of Hygiene and Tropical Medicine; Past President, European Public Health Association; Research Director, European Observatory on Health Systems & Policies.
Professor Susan Michie, Director of UCL Centre for Behaviour Change, University College London.
Professor Melinda Mills, Director, Leverhulme Centre for Demographic Science, University of Oxford; Member of Royal Society’s SET-C (Science in Emergencies Tasking – COVID) committee; Member of ESRC/UKRI COVID Social Science Advisory group.
Professor Neil Pearce, Professor of Epidemiology and Biostatistics, London School of Hygiene and Tropical Medicine
Professor Christina Pagel PhD MSc MSc MA MA (Professor of Operational Research & Director of the Clinical Operational Research Unit, University College London.
Professor Maggie Rae, President, Faculty of Public Health.
Professor Stephen Reicher, Professor of Psychology, University of St Andrews.
Prof Harry Rutter, Professor of Global Public Health, University of Bath.
Prof Gabriel Scally, Visiting Professor of Public Health, University of Bristol.
Professor Devi Sridhar, Chair of Global Public Health, Edinburgh Medical School.
Dr Charles Tannock, Consultant psychiatrist.
Prof Yee Whye, Professor of Statistics, University of Oxford.

Arriving over Athens

...and here's the second letter, dated the same day

An open letter to the PM, Chancellor and UK CMOs and the Government’s Chief Scientific Adviser, 'calling for a targeted and evidence-based approach to the COVID-19 response' 

The Rt Hon Boris Johnson MP, Prime Minister
The Rt Hon Rishi Sunak, Chancellor of the Exchequer
Professor Chris Whitty, CMO, England
Dr Frank Atherton, CMO, Wales
Dr Gregor Ian Smith, CMO, Scotland
Dr Michael McBride, CMO, NorthernIreland
Sir Patrick Vallance, Government Chief Scientific Advise

21st Sept 2020

Dear Prime Minister, Chancellor, CMOs, and Chief Scientific Adviser,

We are writing with the intention of providing constructive input into the choices with respect to the Covid-19 policy response. We also have several concerns regarding aspects of the existing policy choices that we wish to draw attention to.

In summary, our view is that the existing policy path is inconsistent with the known risk-profile of Covid-19 and should be reconsidered. The unstated objective currently appears to be one of suppression of the virus, until such a time that a vaccine can be deployed. This objective is increasingly unfeasible (notwithstanding our more specific concerns regarding existing policies) and is leading to significant harm across all age groups, which likely offsets any benefits.

Instead, more targeted measures that protect the most vulnerable from Covid, whilst not adversely impacting those not at risk, are more supportable. Given the high proportion of Covid deaths in care homes, these should be a priority. Such targeted measures should be explored as a matter of urgency, as the logical cornerstone of our future strategy.

In addition to this overarching point, we append a set of concerns regarding the existing policy choices, which we hope will be received in the spirit in which they are intended. We are mindful that the current circumstances are challenging, and that all policy decisions are difficult ones. Moreover, many people have sadly lost loved ones to Covid-19 throughout the UK. Nonetheless, the current debate appears unhelpfully polarised around views that Covid is extremely deadly to all (and that large-scale policy interventions are effective); and on the other hand, those who believe Covid poses no risk at all. In light of this, and in order to make choices that increase our prospects of achieving better outcomes in future, we think now is the right time to ‘step back’ and fundamentally reconsider the path forward.

Yours sincerely,

Professor Sunetra Gupta; Professor of theoretical epidemiology, the University of Oxford
Professor Carl Heneghan; Director, Centre for Evidence Based Medicine, the University of Oxford
Professor Karol Sikora; Consultant oncologist and Professor of medicine, University of Buckingham
Sam Williams; Director and co-founder of Economic Insight

Professor Louise Allan (Exeter)
Professor Francois Balloux (UCL)
Professor Sucharit Bhakdi (JG University of Main)
Dr Julii Brainard (U. of East Anglia)
Professor Anthony Brookes (Leicester)
Professor Nick Colegrave (Edinburgh)
Dr Ron Daniels (UK Sepsis Trust)
Professor Robert Dingwall (Nottingham Trent)
Professor Fionn Dunne (Imperial Coll.)
Professor Kim Fox (Imperial Coll.)
Professor Anthony Glass (Sheffield)
Dr Andy Gaya (Consultant oncologist)
Dr Peter Grove (Former Dept Health)
Professor Matt Hickman (Bristol)
Professor Elizabeth Hughes (Leeds)
Dr Tom Jefferson (Oxford)
Professor Syma Khalid (Southampton)
Professor David Miles (Imperial Coll.)
Professor Paul Ormerod (UCL)
Professor Andrew Oswald (Warwick)
Professor David Paton (Nottingham)
Professor Hugh Pennington (Aberdeen)
Professor Barbara Pierscionek (Staffordshire)
Professor Eve Roman (York)
Professor Justin Stebbing (Imperial)
Professor Ellen Townsend (Nottingham)
Steve Westaby (Retired heart surgeon)
Professor Simon Wood (Edinburgh)

Appendix: Specific comments on the existing policy path

Any objective should be framed more broadly than Covid itself. To place all weight on reducing deaths from Covid fails to consider the complex trade-offs that occur: (i) within any healthcare system; and (ii) between healthcare, society and the economy.

Individual policy choices within the strategy should be informed by an evidence base. The absence of similar policy interventions to those now being implemented in the past, coupled with the novel nature of the virus, means there is limited existing empirical evidence to inform the effectiveness of said measures. This means most weight should be placed on: (i) analysing what is actually occurring in relation to the outcomes we are targeting; (ii) metrics that can be most accurately measured and reported; and (iii) robust evaluations of interventions imposed, to ensure they deliver actual benefits. We are therefore concerned about the sole reliance on ‘case numbers’ and the ‘R’ to inform national and local policies, as these metrics are subject to significant measurement and interpretation challenges (and further, neither is an outcome that matters to society).

The most pertinent epidemiological feature of Covid-19 is a greatly varying mortality risk by demographic. Mortality risk is highly age variant, with 89 per cent of Covid mortalities in the over 65s. Mortality risk is also concentrated in those with pre-existing medical conditions (95 per cent of Covid deaths). This large variation in risk by age and health status suggests that the harm caused by uniform policies (that apply to all persons) will outweigh the benefits.

Blanket Covid policy interventions likely have large costs, because any adverse effects impact the entire population. These include: (i) short and long-term physical and mental health impacts; and (ii) social and economic impacts.

In relation to health, the impact on cancer is especially acute. ‘2-week-wait’ cancer referrals decreased 84 per cent during lockdown. The impact of this alone has been estimated to be up to an additional 1,200 cancer deaths over 10 years (23,000 life-years lost). Cancer Research UK estimated there are 2 million delayed or missed cancer screenings, tests or treatments. The impact of this broader disruption is uncertain. However, estimates indicate it could be as high as 60,000 lives lost.

In terms of the economy, the OBR’s forecasts are for unemployment to reach 11.9 per cent by Q4 2020. As of July 2020, net debt had risen to £2 trillion for the first time, and public sector net debt is expected to be 106.4 per cent of GDP at the end of the year.

Set against the high costs of these policies, their effectiveness in reducing Covid deaths remains unclear. Focusing on the UK, there is no readily observable pattern between the policy measures implemented to date and the profile of Covid deaths. Caution should therefore be exercised in any presumption that such policy measures will successfully lower future Covid mortalities.

In light of the above, our strategy should therefore target interventions to protect those most at risk. For example, Germany’s case fatality rate among patients over 70 is the same as most European countries. However, its effective reduction in deaths is based around a successful strategy of limiting infections in those older than 70.

Finally, behavioural interventions that seek to increase the personal threat perception of Covid should be reconsidered, as they likely contribute to adverse physical and mental health impacts beyond Covid. Consideration should also be given to whether policies that are intended to ‘reassure’, may in fact reinforce a heightened perception of risk. Providing the public with objective information on the actual risk they face from Covid-19, by age and health status, would be preferable.

Athens Venizelos Airport - walking to departure for England

"So what's your opinion, Simon?"
"My very humble opinion?"
"I am as confused and uninformed - for all my listening and reading - as a serf aware of the growing spread of the great pestilence in the middle of the 14th century. And, you know, historians are still arguing about the Black Death!'
"How about a more arrogant opinion?"
"I'm glad I don't have to have one"
"Oh go on!"
"I thought I had a reasonably appreciation of what was going on with this strange virus in the middle of the year. Now I am confounded. Don't get me wrong. I still have opinions but I have less confidence in them."
"So how would you judge that exercise you were suggesting, asking students to do a briefing to government, on the basis of those two letters?"
"I'd love to try it out. It's not much help but I am tending to go along with the words in that first letter:" 

In a complex system, we should not expect to see a simple, linear and statistically significant relationship between any specific policy intervention and a particular desired outcome. Rather, several different policy measures may each contribute to controlling the virus in ways that require complex analytic tools and rich case explanations to elucidate. While it is always helpful to have more data and more evidence, we caution that in this complex and fast-moving pandemic, certainty is likely to remain elusive. “Facts” will be differently valued and differently interpreted by different experts and different interest groups. A research finding that is declared “best evidence” or “robust evidence” by one expert will be considered marginal or flawed by another expert. It is more important than ever to consider multiple perspectives on the issues and encourage interdisciplinary debate and peer review. While government must continue to support research, some decisions—as you will be well aware—will need to be made pragmatically in the face of uncertainty.  

Linda: "So, basically, that involves governments doing whatever they like" 

"What puzzles me is that I can discern no plausible connection between governments' policies on Covid-19 and their effects, other than to cause delays in the progress of the pandemic ... A puzzlement that confirms my sense of being like a serf in the century of the great pestilence*" (continued on p.94)

23/12/20. An old friend, Ian Coghill (once an environmental health professional) commented: Delaying the progress of the pandemic has been the only outcome of the government's policies. It was probably the only practical one in a free country. Nor has it been a waste of time. It has largely prevented the acute care system being overwhelmed and has allowed time for potential vaccines to be produced and deployed.

29/12/20. We are not only 'locked down', but 'locked in' to a situation that has no end. The Black Death lasted 7 years. Other bubonic epidemics involved slightly shorter ordeals. The 'Spanish' flu lasted three years. CD-19 will last longer, with reverberating collateral damage in other sectors and to many other people. I can't see how any government can moderate lockdown. The virus can recur in those who've had it, Vaccination - touted as the light at the end of tunnel - does not reliably stop people getting the disease or transmitting it. Restrictions on social end economic activity are widely supported among electorates and by opposition parties in government. Many complain that present and suggested restrictions are not stringent enough and too late. 

5/01/2021. Listening to the radio last night I thought I heard .... "I am speaking to you from the cabinet room at 10 Downing Street. This evening guided by every sensible scientist in Europe I handed the Coronavirus and its mutations a final note stating that, unless we heard from them in the near future, that they were prepared, at once, to withdraw themselves from everywhere by 11 o’clock, a state of war would exist between us. I have to tell you now that no such undertaking has been received, and that consequently this country is now in a state of lockdown forever." 

Our daughter reports our grandchildren delighted in proportion to their parents' dismay 

*The Black Death

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Simon Baddeley