Saturday, April 18, 2020

The biggest test of Nicola Sturgeon's career: she must insist that Scotland's lockdown remains in force until it can be safely replaced with a credible 'test, trace, isolate' plan to suppress the epidemic - and if that means facing down the right-wing London media and the Tory 'hawks', so be it.

Government ministers are trying to gaslight us again: no, the UK death toll is not "lower than the modellers expected". It's considerably higher.

As you may have seen, BuzzFeed have another exclusive - this time a supposed leak of the government's exit strategy.  It's difficult to know how much credence to give it, bearing in mind that one key part of it (different treatment for different age groups) was flatly contradicted by Patrick Vallance only a couple of days ago.  However, to the extent that it can be taken seriously, it's a bit of a curate's egg.  There's plenty in it that's pretty alarming, but let's accentuate the positive for a moment: WHO advice on the vital importance of using mass testing and contact tracing to control the epidemic seems to have been accepted, albeit several weeks later than it should have been.  The fact that the penny appears to have finally dropped is underscored by an apparent implication that the lifting of lockdown will have to be delayed if testing and contact tracing capacity isn't up to scratch by the desired date of early-to-mid May (and, let's face it, it probably won't be).

The bad news is that the insanity of "herd immunity by mass infection" still doesn't seem to have been entirely banished - SAGE are apparently saying the final resolution of the problem can only be the development of a vaccine, or herd immunity by infection.  However, that has to be put in the context of modelling that shows herd immunity can only be achieved by two means - either a) by allowing the health service to collapse, resulting in a totally unacceptable number of deaths, or b) by an epidemic so slow that a vaccine would almost certainly be available long before its end.  So to all intents and purposes, there's a de facto acceptance that a vaccine in 12-18 months' time is the way out, and the only remaining question is how many people the government will allow to pointlessly die or become infected between now and then.  I get the troubling sense from the BuzzFeed piece that the number might be a lot higher than most of us would be comfortable with.  However, as this process unfolds it will hopefully become clear from international best practice that there is a 'sweet spot' of moderate social distancing measures and extremely rigorous contact tracing which will allow the economy to function, while still keeping the number of new infections persistently low.  South Korea have been demonstrating for weeks that it's perfectly possible, but if it happens in European countries like Germany as well, the government might finally be forced to take the lessons on board.

There's a suggestion that over-70s and other vulnerable people might be told to avoid social contact for 12-18 months, which sounds completely unsustainable to me.  However, in a perverse way it's reassuring that the idea is being floated, because it's a tacit acknowledgement that herd immunity can't and won't be achieved before the arrival of a vaccine.

There's one part of the BuzzFeed article that made my jaw drop to the floor -

"There is increasing optimism in Whitehall that...the peak of the coronavirus crisis in this country will not be as devastating as feared by modellers a month ago.

Forecasts by government scientists had envisaged the NHS facing a monumental task to not to breach capacity at the peak, with the possibility of the health service running out of intensive care beds and ventilators, leading to tens of thousands of extra deaths.

As Britain approaches the peak, ministers are now quietly confident that this disaster scenario will not happen. Part of the reason is that it is now believed fewer people have contracted the virus than the experts expected, and that the nature of the virus itself is different to their initial understanding, with fewer patients requiring ventilation."

Where to start with such gibberish?  First of all, it wrongly implies there was a single forecast in the modelling for the overall number of deaths.  There was not.  There were radically different forecasts for various scenarios in which the government applied different measures -

1) If the government did nothing, there would be around 500,000 deaths.

2) If the government followed their original herd immunity strategy, by shielding certain groups but otherwise allowing normal life to largely continue, there would be 250,000 deaths.

3) If radical social distancing measures were introduced (ie. lockdown or something approaching it) there would be 20,000 deaths or fewer.

The government chose the third option, so the relevant forecast is 20,000 or fewer - and that has probably already been exceeded if care home and community deaths are taken into account.  With several hundred deaths still being reported every day, we could easily finish this wave of the epidemic with more than double the number of deaths that the modellers predicted.

Not for the first time during this crisis, it looks like government ministers are trying to gaslight us.  They're seeking to persuade us that fewer people have been infected than the modellers expected, when in fact the only reason that's happened is because the modellers persuaded the government to change course and impose a lockdown.  It's beyond my pay grade to know whether it's true that fewer patients than expected are requiring ventilation, but if so it's extremely hard to understand why the mortality rate is so much higher than the modellers predicted for the lockdown scenario - especially given that the public's compliance with the rules has by all accounts been considerably better than the modellers allowed for.

Wednesday, April 15, 2020

The whole world, from Jacinda Ardern to Donald Trump, from Anthony Fauci to Neil Ferguson, has said no to the "herd immunity" madness - but, never fear, Iain Macwhirter (of all people) remains a devoted fan

I don't think I'm alone in having been genuinely confused by Iain Macwhirter's evolving (or perhaps 'meandering' is more accurate) position on the "herd immunity" debacle.  When I first spoke to him about it several weeks ago, there's no doubt that he at least partly misunderstood the concept.  He had listened to one of Jason Leitch's many media interviews, and had formed the false impression that only a small percentage of the population would need to be infected to generate herd immunity.  Based on that misconception, it's not hard to see why Iain found the idea so seductive - if the virus would go away for good as soon as, say, 5% or 10% of people were infected, and if it could somehow be contrived that those 5% or 10% were almost exclusively young and healthy people, then the strategy would make a great deal of sense.  The problem is, of course, that it simply doesn't work that way.  Herd immunity only comes about when the virus hits a brick wall because most of the people it attempts to infect are already immune - and that in turn requires the majority of the population to have either been vaccinated or infected.  Jason Leitch never made any secret about that - he was talking about allowing the virus to move through the entire population.  Patrick Vallance stated that at least 60% of Britons would need to be infected (and that may have been an underestimate, given that calculations of how infectious the virus is have drifted upwards since then).  

And we've already seen how the notion of limiting infections to the 'non-vulnerable' segment of the population is a pipe-dream.  It's not just that elderly and vulnerable people in care homes haven't been successfully 'shielded' - they've actually been hit by the epidemic to a disproportionate extent.  That was entirely foreseeable, given that people will always have to go in and out of care homes.  The only way to keep the virus out of a care home is to make sure there isn't much virus outside.

At some point, the penny dropped for Iain that herd immunity required an epidemic of biblical proportions, and another penny dropped that the scientific advice the UK and Scottish governments were receiving was at odds with the advice in other countries.  He said to me himself that the government found itself in a terrible quandary because its advisers were in a minority of one from an international point if view.  Surely these realisations must have given Iain pause for thought?  Nope, not a bit of it.  Today, even after all the carnage we've seen, even after the succession of U-turns from the UK administrations when the original plan proved to be completely unworkable, Iain has penned yet another column suggesting that British science will in the long run be proved right and the rest of the world will be proved wrong.

I don't know how to break the news to him, but the UK and Scottish governments' original scientific advice has already been proved wrong.  Totally, comprehensively, and catastrophically wrong.  How do we know that?  Because the advisers went on the record in February and early March about how they thought events would play out when the herd immunity plan was put into operation.  Catherine Calderwood stated that it would be business as usual at the peak of the epidemic - some people would be mildly ill, some people would be very ill, but we'd accept that and get on with our daily lives, just as we would during a bad flu season.  Jason Leitch said that even the most vulnerable people wouldn't be asked to avoid face-to-face contact completely, and indeed that their contact with family members would actually increase.  And Patrick Vallance stated that any form of lockdown in the UK was highly unlikely.  

How does all of the above tally up with where we actually are now?  Well, we're currently in nationwide lockdown, with the vulnerable told to isolate completely, and with everyone else told to stop going about their normal lives and to stay at home except when travel is absolutely essential.  Life in Britain is now practically the opposite of what it would look like if herd immunity had been viable in the way that the advisers fondly imagined.  They thought this virus was akin to a bad flu.  This is not the flu.  The number of deaths that would have to occur to achieve herd immunity prior to a vaccine becoming available would be utterly unacceptable to any reasonable person - around a quarter of a million in the UK, if the modelling is to be believed.

Iain criticises "Scottish nationalists" who think that the main problem is that Scotland has been tethered to a disastrous British policy, and points out that Nicola Sturgeon genuinely believed in the advice she was receiving, just as much as ministers in London did.  That's true.  She did.  But here's the thing: she was demonstrably wrong to believe that advice, and she should have been paying heed to the fact that the leading experts of the World Health Organization were saying something radically different.  There were, to be fair, mitigating circumstances: she was probably sitting in on briefings where the UK government's view was being presented to her baldly as "the science", and she may have only been dimly aware - perhaps totally unaware - of the different position taken by the WHO and scientific advisers in most other countries.  But that excuse no longer holds - she's seen with her own eyes that the confident predictions of the UK advisers were wrong, and like the rest of us she's now up to speed with the strategies that were adopted more successfully elsewhere in the world.  So what matters more than the mistakes she made a month ago is whether she's going to rectify those mistakes now, and there are some tentatively encouraging signs that she might.  She's started making reference in her press conferences to 'testing, tracing and isolating' as a crucial part of any lockdown exit strategy, which is exactly what the international experts have been crying out for all along.

Iain states that mass testing will only make sense when an antibody test is available.  Nope, the opposite is true - mass testing to suppress the epidemic would have to use a test that shows whether someone is currently infected, not whether they were infected at some unknown point in the past.  It's knowledge of current infections that opens the door for the all-important contact tracing.  Admittedly, people being tested would have to get their results much quicker than the UK seems to be managing at the moment - contact tracing four days after the event is not much use.  But if faster tests can't be used, contact tracing can still occur if people are diagnosed on the basis of their symptoms.

Iain makes a 'truthy' observation that epidemiologists know that 80% of the population are bound to be infected sooner or later, and nothing can stop that happening because there is no vaccine.  Nope, that's not what they say at all.  Projections of an 80% infection rate (in reality you'll see anything from 50% to 80%) are based on the assumption that governments don't intervene and that the public don't change their behaviour spontaneously.  The famous Imperial College paper went out of its way to point out that both of those assumptions were thoroughly implausible.  A new study for the French government estimates that, due to the lockdown, only around 1% to 6% of the French population have been infected so far.  If that's right, anything between another 9 and 59 waves of the epidemic, of equal severity to the one we've just seen, would be required to produce herd immunity.  If all that governments do is slow that process down sufficiently to prevent total collapse of the health care system, it would take many years and a vaccine would almost certainly be available long before herd immunity was achieved.  That being the case, ie. if everyone knows a vaccine will be the exit strategy in the real world, it's ethically indefensible to allow hundreds of thousands of people to die in pursuit of an unattainable objective.  No wonder that the French government seem to have concluded that a full-on suppression strategy, involving mass testing, contact tracing, ongoing social distancing and face-masks, is now the only game in town.  That will be the new normal until the vaccine is ready.

Iain sneers at people who criticise Nicola Sturgeon for "listening to the wrong kind of scientists", or for suggesting that the scientists she did listen to are guilty of "British exceptionalism".  But come on now.  It's not really good enough to say "any scientists will do".  If there's a dispute between the scientists employed by the government of one small country, and the world-leading scientists of the relevant international body, I'd suggest you'd need to have an outstanding reason to ignore the gold standard science of the international body.  What's Iain's reason?  Ah, here it is -

"Britain has some of the best epidemiologists in the world."

And that's it.  Perish the thought that "British exceptionalism" might have played any part in this disaster.

Tuesday, April 14, 2020

Is Jackson Carlaw right to think he's going to be the new Clement Attlee? (Caution: spoilers ahead)

You may have seen that Scottish Tory leader Jackson Carlaw unintentionally provided the nation with some much-needed hilarity the other day with the most contrived explanation so far of how, against all available evidence, the Tories are supposedly going to storm to victory in next year's Holyrood election.  He wants us to believe that, like Churchill, Nicola Sturgeon is "winning the war" (an implicit acknowledgement that her handling of the crisis is greatly increasing her popularity), but that he, Jackson Carlaw, will be like Clement Attlee and "win the peace".  

It's a curious comparison, to say the least.  Britain was completely broke in 1945, and yet years of hardship and struggle meant that the working class were ready to demand change that hadn't seemed so urgent to them when the country was far better able to afford it.  Carlaw seems to think voters will react to the current crisis in completely the opposite way by demanding less change at the end of it than they otherwise would have done.  

Or perhaps he just means that governments and leaders can seem wildly popular during a crisis, but that things will look very different when an election comes around?  That's sometimes true, but if that's what he's getting at, the Attlee comparison is still misconceived.  There was polling done during the Second World War that suggested a handsome Labour lead (albeit people didn't take it seriously at the time because political polling was in its infancy).  It simply wasn't the case that Churchill was the people's choice in wartime but not in peacetime.

Or perhaps he means there'll be a reappraisal of the Scottish Government's handling of the crisis in the cold light of day?  Maybe there will be, but the main criticism that will be levelled is that they remained too much in lockstep a few weeks ago with the herd immunity madness from London.  It's hard to see how the Scottish Tories can make much capital out of "you were agreeing with the London Tories too strongly".  It's been particularly extraordinary to see Carlaw accusing the SNP of a lack of transparency over care home deaths, given that everyone knows the Conservative government at Westminster is being considerably less transparent on that subject than the Scottish government is.

Carlaw thinks the SNP will "look ridiculous" if they press for independence in the 2021 election in spite of the events of this year, and that doing so could be a recipe for a surprise defeat.  That may or may not be true - anyone who claims to know for certain what the long-term effect of current events will be is deluding themselves.  But it does seem likely that if the public cease to have patience for politicians pushing for independence in the near future, they'll inevitably react in exactly the same way towards politicians hellbent on the hardest possible Brexit.  It may be that what Carlaw has really done is put his finger on the reason why his party should actually be expecting a drubbing next May.

Monday, April 13, 2020

A second lockdown - which would be harsher and longer - is inevitable if we lift the current one prematurely, and if we don't start testing, tracing and isolating

Over the last couple of days, a number of people on social media have been collecting statements made by the Scottish government's scientific advisers prior to March, to demonstrate how irreconcilable they are with the statements they are making now and also with the facts on the ground that we all inescapably recognise.  Even as someone who has been following this closely, I was pretty stunned by how total some of the contradictions are.  Here's a selection...

Before mid-March: "Throughout this epidemic, it will be business as usual.  People will get ill, some people will get very ill, but we'll accept that and get on with our normal daily lives."

Now: "There can be no business as usual.  Stay home, protect the NHS, save lives."

Before mid-March: "We have no choice but to pursue herd immunity by allowing the virus to move through the entire population.  Even though this virus has only been around for three months, we know that people will rarely if ever get it twice, so as long as we successfully manage a massive epidemic now, it won't pop up again in future."

Now: "Pursuing herd immunity is not our strategy and has never been our strategy.  That would never have been viable because it is not known whether people who have been infected develop lasting immunity."

Before mid-March: "Large public gatherings are fine, because the evidence is that the virus is not transmitted in those settings, particularly if an event is outdoors.  Even if we eventually stop large gatherings, that'll simply be to free up capacity for the emergency services, not to slow the spread of the virus."

Now: "Any gathering of more than two people, even in the open air, puts lives at risk."

Before mid-March: "Closing schools would be positively harmful.  The virus does not spread among children, and key workers might have to stay off work to look after their children if schools are closed."

Now: "School closures have an important role to play in stopping the spread of virus between households."

I haven't heard any public acknowledgement of these U-turns.  That maybe speaks to a failure to treat people as adults, because there can be no doubt that ministers and their advisers privately realise that what they were previously saying has been proved comprehensively wrong.  My hope is that there is now an understanding that the big mistake prior to mid-March was to listen only to the exceptionalist "British science" and not heed the clear message of the World Health Organization that the virus must be suppressed and controlled by means of mass testing, contact tracing and ongoing social distancing. 

If that lesson has been learned, it would mean the Scottish Government using whatever leverage they have at this critical juncture to argue against the siren voices in Tory circles calling for a premature lifting of the lockdown.  Troublingly, however, Jason Leitch's appearance on breakfast TV this morning left the impression that all of the same mistakes may be about to be repeated, and that Scottish Government spokespeople will simply carry on faithfully echoing whatever is being said in London.  

Leitch talked of "balancing" the harm of lockdown with the harm caused by the virus.  He said at present the priority must be protecting people from the virus, but at some point that would change and the priority would shift to ending the harm caused by lockdown.  This is fundamentally flawed thinking, because these harms are not actually in competition with each other - they are all interrelated.  The countries that have avoided the harms caused by long, harsh lockdowns are the ones (most obviously South Korea, but there are others as well) that took the early action necessary to suppress the virus.  We, on the other hand, left schools open, actively encouraged people to go to large gatherings (yup, that was Jason Leitch on an earlier breakfast TV appearance), and abandoned testing and contact tracing.  That's why people are suffering from a full lockdown now.  They will suffer even more from an even longer, even harsher second lockdown at a later stage if we lift the current measures prematurely, because the NHS will very quickly find itself in total collapse and the government will once again be left with no other choice. 

What the Scottish Government should be saying privately and publicly is that lockdown must only end when a strategy is in place to keep the numbers of new infections persistently low.  By doing that, we don't have to 'balance' or 'prioritise' the harms caused by the virus and by lockdown - we'd be resolving both sets of harms simultaneously.