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Testing: the Key to Escaping Lockdown.
Graphic from German Patent & Trademark Office.

Summary: We need to make intelligent decisions about what is the right strategy when we progressively soften or remove any of the current restrictions on our behaviour in the UK. We need to accumulate a comprehensive dataset of information about the behaviour patterns of each and every person who becomes infected. With 5000 new Covid-19 cases detected each day we will be able to generate a major statistical database. This would allow us to make intelligence-led decisions about how to manage our escape from Lockdown as quickly and efficiently as possible.

The UK government appear to be allergic to the idea of even talking about how we might ease and eventually leave Lockdown. Perhaps the main strategic error in the UK apart from just doing things far too late and slowly was the decision to abandon testing in place of hoping for herd immunity. All the evidence is that probably only 15% are immune which means that the rest of us still have it to live with or die with. The dangers we are faced with from Covid-19 are in no way diminished by spending many weeks in Lockdown. We have to decide how to manage intelligently the way forward. In another piece (see: http://outsidethebubble.net/2020/04/14/escape-from-lockdown/) we have discussed how different aspects of our containment might be relaxed. The problem is we have very little information about what is happening in the UK and where those infected caught the disease. Only by understanding in detail what aspects of our behaviour is leading to those individuals being infected can we make progress.

It does seem to be agreed fairly widely that any escape from Lockdown is going to depend on a much greater and more aggressive approach to testing for people who have the disease and later for those who may have had it in the past. However there is no point in mass testing until we have a clear idea of what we hope to get out of it. In the UK we have excellent capabilities in artificial intelligence combined with data mining particularly with heterogeneous data. A good example is the work that was being done a few years ago by Cambridge Analytica. There are many other organisations working with other equally complex datasets and we need to use their skills to guide what we do next. The suggestion that the new whizzy smartphone app will sort everything out for us is probably pretty naïve unless there is some considerable investment in analysing the data produced and reacting to it as a matter of urgency. If this is all underway good and well but it is difficult to believe it will be enough.

We still have nearly 5000 new cases of Covid 19 each and every day in the UK. We need to institute as a matter of urgency a serious attempt to find out more about each new case in order to develop a much better understanding of where the problem seems to be in our society. All the evidence is that the British public appear superficially to be respecting the Lockdown pretty rigorously and respectfully. City streets are deserted. Shops are closed. Places of entertainment, restaurants, cafés and bars are all closed. So where is this infection coming from? These apparently very basic questions are ones that we simply don’t seem to know the answer to.

It is important that everyone who is tested is asked all these questions. Honestly is critical and it must be made clear that there will be no penalty for admitting going outside the present lockdown rules. The range of questions that need to be asked has to be very comprehensive and should include:

  • Location and environment: Where do you live? Kind of home: house/flat/apartment? Size of home? Number of rooms? Number of people in lockdown in your own home? Any garden? Access to green spaces nearby?
  • Employment: What is your job? What is your position in the organisation? Where do you work? How do you get  to and from work? Private car, bicycle, walking or public transport? If public transport question is it crowded and how close do you find you are to other travellers? What is your precise job? How many people do you work with? Do you work in a relatively crowded environment where social distancing is difficult or impossible to maintain? What do your employers provide to ensure your own safety and allow you to follow social distancing rules?
  • Financial: What approximately is your current income now? How long has it been at that level? What was it before the pandemic force the Lockdown?  how do you feel you are managing now? What are your immediate expectations financially? Are you anxious, concerned or very apprehensive about the future? Has that been affecting your state of mind and potentially your health?
  • Family: Family disease history, colds or influenza or any other recent bugs? Has the patient or other family members any other medical conditions of any significance? Diabetes, heart disease, pulmonary problems or anything else? Allergies including hay-fever and asthma?
  • Close Family: Do you see or meet close family members? How careful are you to social distance yourself properly? Are they cautious and meticulous about keeping themselves safe? Do they have any potential problems with Covid-19 such as the elderly or frail? Should they be considered at risk because of your possible infection?
  • Managing Lockdown: How are you managing generally? Stress levels? Behavioural problems with other members of the household? Questions designed to tease out any suggestion of domestic abuse towards partners, children, parents or anyone else living with you? How do you contact people outside your home? Telephone or video such as Zoom? Do you have adequate  internet access?
  • Behaviour: Facemasks. Do you use them at all? Do you wear them whenever you go out of the house? When you go out for exercise? When you visit supermarkets?
  • Behaviour: Gloves. Do you use gloves at all to give you a degree of protection against contamination through touching? How meticulous and careful do you think you are about that?
  • Behaviour: Handwashing and use of hand sanitisers: how often do you thoroughly wash your hands? Whenever you come back from being outside? Or only when you come back from shops? Or after taking exercise?
  • Behaviour: Meeting other people: Do you ever see people you know apart from at work? Where do you meet them? Do they use facemasks? Do they social distance properly? Have any of them recently mentioned symptoms or just feeling slightly under the weather?
  • Behaviour: Exercise: How much do you take? How many times a day and how long do you exercise for?
  • Pets: do you have pets and if so what? do you take them out for exercise?

All these tiny pieces of information from one individual  will provide a single set of instances which will not, in itself, be significant. However combined with another 5000 that we already test each day we should expect to see significant correlations that build up in importance. They would tell us very early on, for example, whether people are more or less likely to be being infected at work or in shops, in the street or other places. We would know very quickly whether facemasks should be used much more widely and how important they might be for this.

Each questionnaire should be completed within 10 or 15 minutes while the patient’s test is being processed. These  questionnaire results are really important and it is essential that people are trained to carry them out effectively and reliably. Ideally questionnaire should be completed by an individual trained to do so and not necessarily a medical professional.

The results of such a survey have the potential to give us all the basic information we need about what aspects of British behaviour are likely to be more problematic. These are the areas which should not be relaxed and possibly addressed by stronger regulation. The results will also tell us what appears to be relatively harmless behaviour. This would allow some of the restrictions we have now to be dropped fairly quickly with relative confidence that that will have only a minor effect negative effect on infection.

Only by gathering this sort of information routinely can we expect to have any intelligence driving our escape from Lockdown. A good understanding of British behaviour today that is currently leading to additional infections has to be developed. In this way we might have an intelligence based route by which the UK might escape from Lockdown.

Escape from Lockdown.
Montage of facemask styles in Malaysia in January 2020. (AP Photo/Vincent Thian)

Summary: The British government seem surprisingly reluctant even to talk about how we might manage the winding down of the current fairly Draconian Lockdown. They have not really understood the importance of managing this as soon as possible and getting discussions going. Many are finding themselves very badly affected by it all and wealthy middle-class individuals in government and the media need to engage now with what is actually happening to the poor. This piece is intended to start a conversation and think about how we might make progress right now that would give individuals at every level the feeling that we can see the time when things substantially return to normal.

Public compliance with the Lockdown has been surprisingly good. We all seem to know exactly what we should be doing, and most of us are indeed doing it. However there are short-term concerns that there are relatively large numbers in the UK who are very close to destitution without any income and without any alternative sources of food. You can no longer turn up at a food bank and hope to get anything. In my own area some food banks have found donations have dropped by more than half while demand has more than doubled. People can only access food banks with a note from their GP for example. However as surgeries are closed those are now very hard to get.

A recent piece (http://outsidethebubble.net/2020/04/06/exit-from-lockdown-take-back-control/ ) have tried to focus on what could already be done without significant effect on the workings of the Lockdown but would give the public an indication that there is light at the end of the tunnel. In addition, another piece (http://outsidethebubble.net/2020/04/12/lockdown-collapse/) looks at the social consequences of not addressing urgently the extreme poverty and destitution facing so many in the UK now. This piece tries to put together an outline of how we might see the escape from Lockdown actually playing out. At present the British government seem quite reluctant even to think about it, concentrating above all things on preserving the NHS. However poverty and the economy are starting to move up the priority list and will soon have to be squared against the support that everyone is keen to give the NHS.

There are interesting examples from around the world about how this might be handled. Probably the least lockdowned country in Europe is Sweden. They have relied much more on the good sense of the people to do the right thing. Elderly and frail people know they must isolate for their own health and security while younger people are still able to continue much as they have done. The PM of Sweden has been criticised for not closing bars, café’s and restaurants and may indeed impose tighter restrictions on them medical soon. Higher education is now only online. Primary and secondary schools remain open. Sweden’s relaxed approach to the epidemic has also meant they are suffering from the same shortage of PPE and equipment that they are in the UK because they also never really thought it would become so desperately important.

One of the key changes that we need to implement in the UK in order to move forward is to increasingly pass responsibility for self protection to the individual, as it is in Sweden, and away from relying on following rigorously the instructions from government dictat. A key component of this must be the use of facemasks. Supplies of course in the UK will be hopelessly limited but effective facemasks can be constructed from fabric pieces or by using scarfs in single or multiple layers. It is clear that a thin layer of paper held on your face by a couple of rubber bands is pretty inadequate and more substantial protection from more substantial facemasks is highly desirable. Individuals must be reminded that the dangers of contracting Covid-19 are just as serious as they always were. Your facemask protects others should you be infected but be asymptomatic. It also gives you a first level of protection against infection by others. However it is your responsibility to protect yourself and others from this deadly disease which has in no way been weakened by the weeks of Lockdown. It is just as lethal now as it was at the beginning. Facemasks will provide one level of protection. Wearing gloves and eyewear such as glasses, sunglasses or goggles further enhance protection. Each of us needs to address how we manage the risks that we will come across in everyday life. Each of us has to look after not just ourselves but everyone that we come into contact with. There is increasing evidence that people catch the disease by breathing and when talking which further increases the importance of wearing facemasks.

Some of the current restrictions are really excessive and almost vexatious. A few could be lifted almost immediately and would give the public a sense that progress is being made. Some other areas are inadequately taken care of and so some additional restrictions need to be brought in.

  • We should remove all restrictions of being out of the house provided the social distancing rules are maintained at all times.
  • We should permit people to drive or travel moderate distances for leisure or exercise.
  • Require everyone to routinely wear facemasks and make that compulsory wherever there is any risk of coming closer than the official 2 m separations. Customers visiting supermarkets and any other business premises should always wear facemasks as should the staff and other employees of the business.
  • Public transport users and drivers etc must wear facemasks at all times.

There are other areas that can be addressed almost immediately.

  • Parks and open spaces should be opened to the public unless they will attract such a high density of visitors that those visitors will find it difficult to maintain social distancing rules. This would allow places such as National Trust parklands to open though not initially their shops and certainly not the cafés. For example a botanic garden could open the parkland but put greenhouse and exhibition areas s off limits. They could allow entrance to season ticket holders and, if space allows, other members of the public provided overall numbers can be managed to maintain social distancing rules.
  • There are issues about reopening children’s playgrounds. Children are notorious for wanting to play with one another and therefore pass any infections around to others. How this is handled not only in specific children’s playgrounds but also in more general open parkland has to be considered carefully
  • Businesses that are currently closed should be able to operate provided they can manage social distancing regulations for staff, other employees and customers. All these three categories must wear facemasks at all times. Employers should be legally responsible for ensuring this is carried out.
  • Other businesses should be allowed to operate but only provided staff and customers can maintain social distancing rules at all times. All customers and staff should wear facemasks at all times. Again, safety must be a legal responsibility of the employer/business owner. If it is felt that business reopenings should be done progressively it would be best probably to start with small businesses that should be easier to get going and start to bring some life back to the high street.

The second phase will include allowing some social gatherings to be restarted. This is a particularly tricky thing since I know as a grandparent how much I want to see and hug my grandchildren as I have done since they were born. However we elderly are still as much at risk as we ever were and relaxation of some of these rules will inevitably increase those risks if we are at all casual about self protection. Parents need to protect their parents as they have been doing so far. It is inevitable that the elderly and frail will continue to be fairly isolated almost to the end of this escape from Lockdown. Only the vaccine will give full confidence that the elderly can return to normal life. This will be hardest for them.

The next phases could be phased in gradually possibly as follows:

  • We can start by permitting junior schools to open. The onus must be on the managers of the schools to make sure that the staff always wear facemasks.
  • Some sporting events can be started but played behind closed doors (so no spectators). Only sport that can be carried out to provide full social distancing should be permitted initially. Some can be done fairly easily such as golf, tennis though it is clearly difficult to imagine sports like rugby being a success with full social distancing. Soccer is very popular but it is not clear how easily players can be protected initially.
  • Senior schools and universities can gradually be brought back into function, again always requiring that staff, other employees and students can manage with appropriate degrees of social distancing at all times. Neither of these are particularly urgent because the target time would be the beginning of the autumn term. If that cannot be managed then there is little point in opening them until the beginning of 2021.
  • Cinemas and theatres could be operated by requiring that rows and seats are left between members or family groups of the audience. Whether this could be done while maintaining any kind of commercial viability is another question entirely. We are getting remarkably used to being entertained over the Internet and the pressures for getting back into cinemas and theatres are not what they might otherwise be.
  • Similarly, it is likely that restaurants, cafés and bars only reopened after the pandemic is substantially over vaccines are available. These are venues that are fundamentally social and where eating and drinking inevitably means removing ones facemask. Unfortunately this means that the economic pressures on such businesses by the end of the year will be very acute.

It is essential that we appreciate that what we in the public have learned in recent weeks about keeping ourselves safe will have to be maintained until we are sure we can be saved by other routes. Ultimately that has to be with the availability widely of an effective vaccine. There is a great deal of effort going on into these vaccines and it will help that the enthusiasm to find solutions will mean that trials that are usually sequential can be carried out in parallel. The

We must also remember that if we find that we have moved too quickly in any of these areas then we simply have to be prepared to reverse them. It is important that the country starts to engage with the conversation about how all these matters are to be handled. Many of the suggestions will have to be considered carefully because each will have health aspects but also economic aspects. Our economy will be damaged badly by coronavirus particularly given how long it has gone on and how poorly prepared we have been to manage it. Yet it is our economy that will provide the opportunity to start to repair the damage that has been done and hopefully to move on well beyond that.

Massive Underreporting of Covid-19 Deaths
A care home in Worthing, typical of many in the UK.

Summary: The daily Covid-19 deaths statistics only referred to deaths in hospital. Deaths in care homes and at home are only revealed much later. Scottish care home death statistics were partially announced this morning. On the assumption that these will be followed in the rest of the UK pro rata then we should add well in excess of 5000 additional deaths to the UK count and probably very many more. Per capita it seems inevitable that UK deaths will be one of the highest in the world and exceeding those off Spain and Italy.

The death statistics quoted by government ministers and used as the metric of success in the UK in managing the pandemic only reveal the level of deaths in hospital. Others who die at home or in care homes are not recorded. They only start appearing well after the event when the death certificates are processed and the cause of death is given as being due to Covid-19. Those figures are compiled into weekly total debt figures that are only mentioned in passing. For the week ending 27 March 501 deaths were registered in hospital and only 20 in care homes, plus 15 at home.

Around 400,000 people are currently resident in British care homes. We have no idea of the incidence of Covid-19 infection but we do know that in some care homes as many as 70% of residents have been affected. The only clear statistic that we have of care home deaths was given this morning (13 April) for Scotland by the Cabinet Health Secretary. She said on the Today programme that 46% of all Scottish care homes have notified her of at least one Covid-19 death. That gave a total of 406 deaths.

We do not have the figures for England, Wales or Northern Ireland. However we can make some simple calculations. The population of Scotland is 8.2% of that of the UK. Just simply accepting that there were only 406 deaths in Scotland (and the words used were “at least one death”) then simply pro rata we would expect there to be around 4500 deaths in the remainder of the UK making a total of about 5000 nationwide.

Unfortunately, we know from many instances within England that there are often more than individual deaths per care home. We do not have those numbers for Scotland but if we make a simple assumption that on average in each Scottish care home that was not a single death but actually 1.5 deaths then that would correspond throughout the whole of the UK a total death level of about 7500. The UK has officially recorded 10,600 deaths. If we add in those now estimated for care homes the total is in excess of 18,000 before we add in those that may have died at home. Increasingly we are hearing that those who are frail and elderly but become infected at home are generally not being taken to hospital if treatment will be problematic and those deaths are therefore not recorded in the hospital figures.

It seems inevitable therefore that the British death rate from the Covid-19 pandemic is already greater than recorded in Spain or Italy. The population of Germany is about 25% greater than that of the UK yet Germany has managed to keep deaths down to just over 3000.

The conclusion has to be that the real death rate in the UK from Covid-19 will be one of the highest per capita in the world, a remarkable achievement. The well documented delays in the UK for taking the epidemic seriously and trying to manage it without adequate planning or anticipation is nothing short of criminal.

Note added: morning of 14 April:

On the Today programme the head of the largest care home grouping in England, HC1, said that two thirds of their care homes (232 ohms) have reported infections, a total of 2447 cases with 311 deaths and one staff member who died. This suggests that the factor used above of 1.5 deaths per care home is not too far away from reality and that the upper limits described above are more likely to be correct. Richard Murphy on his blog (https://www.taxresearch.org.uk/Blog/2020/04/13/we-wont-just-have-the-worst-health-outcome-in-europe-from-covid-19-we-will-probably-have-the-worst-economic-one-too/) confirms that other European countries are finding that care home deaths are much the same as hospital deaths across Europe.

Lockdown Collapse?
Easter Saturday in Cambridge: Lockdown well under control! (Cambridge News photo)

Summary: The much delayed Lockdown in the UK has been managed well by the majority of our population. The strategy of defending the NHS at all costs is substantially a consequence of years of underfunding because of austerity. There are other consequences of the Lockdown that are becoming rapidly more critical. There are substantial numbers whose income has fallen to zero and who simply cannot find the money to eat. These numbers are so great and growing so rapidly that we cannot expect the present Lockdown to be maintained for much longer. Public tolerance is finite. The most abject poverty must be managed by distributing funds as widely as possible as a matter of urgency. Responsibility for managing the pandemic needs to be passed increasingly to the individual to take responsibility for their own safety and that of their family. Businesses should be allowed to reopen provided certain essential arrangements are made for staff, customers and any casual workers involved. We all need to start using facemasks much more widely as the Lockdown is reduced over a small number of weeks.

The Lockdown has been surprisingly well-tolerated in the UK, despite the excellent weather and the Easter weekend. Unfortunately it isn’t working all that well. The number of new cases, hospitalisations and deaths continue to mount. Increasing evidence from Chinese studies suggests that social distancing at 2 m is not enough. Simply breathing the same air as infected individuals and talking with them is most likely one of the main ways the virus propagates. Recent studies suggest that only a low percentage of the UK population have already had Covid-19, probably <15%. Herd immunity is a long way from reality. Hopes that a vaccine might be available in September have been raised by efforts in Oxford but it will take some time thereafter to produce vaccine in the quantities needed to treat a major fraction of the British population. Predictions suggest widespread availability towards the end of 2020 if everything goes well.

The reality is that the UK government ignored what health experts were saying in mid-January about the outbreak in Wuhan, an outbreak that was worsened by the Chinese not wanting to stop celebration of the Chinese New Year in late January when large numbers traditionally travelled to visit their families. The UK government had been in denial about the threat to national security of a pandemic even though the Cygnus exercise in October 2016 had shown that the UK capacity to deal with a pandemic was so poor that it was “too terrifying” to be publicised. Further warnings were given regularly but ignored substantially by the Tory government still obsessed with austerity, something that compromised greatly the capacity of the NHS to deal with the health requirements of the UK anyway. The Tory government, keen to distance itself from anything the EU might do, no matter how it might help the UK, decided not to be involved in the four EU procurement schemes to order a wide range of PPE equipment. When eventually the UK got round to it, most suppliers were already committed to supply elsewhere.

Boris Johnson was happy to rely on British exceptionalism. The pathetic worries of Johnny Foreigner could be ignored. In early February Johnson made it clear that trade and commerce were of much higher priority than coronavirus. In a speech in Greenwich, he stated that the UK would emerge from the exaggerated calls for action, taking the role of a Marvel superhero leaping out to save the planet. To ignore any country that entirely shut down a city with a population greater than that of Greater London counts as one of the great examples of government negligence in modern times. Then to delay by perhaps five weeks now translates  into many thousands of totally unnecessary deaths. It has also caused extraordinary damage to the UK economy and to its people more widely.

Large numbers of the UK workforce found themselves unemployed and with zero income three weeks ago. It has been known for some time that around 40% of UK non-pensioner households have savings that will barely pay for one months worth of household bills. Already the Food Foundation reports a You-Gov poll taken last week that found 1.5 million households have not eaten for a full day as they simply have no money and no access to food. In total 3 million had to skip some meals during the week. Anecdotal reports of increased hospital admissions due to malnutrition are concerning. Mechanisms for funding unemployed people with zero income have barely been established and what there is seems to move on geological timescales.

Economists such as Richard Murphy (https://www.taxresearch.org.uk/Blog/) have long advocated simply giving a modest fixed payment to everyone in the Inland Revenue’s PAYE lists with additional mechanisms to give money directly to those not currently part of the formal wage earning/tax paying community. There are a surprising number that would be missed if this was restricted to HMRC lists. It is quite possible some money will go to people who do not need it or do not deserve it. That has to be accepted as a minor detail of little consequence in the big picture as speed is of the essence here.

Widespread starvation risks leading to some civil insurrection. At present the police have a major responsibility for managing the Lockdown. However austerity has cut police numbers to the bone and it is important that the police are free to keep order more widely should the Lockdown start to crumble. Alternative approaches to keeping the epidemic under control need to be developed. Predictably, the government has barely started thinking about that and are a long way from deciding how to manage it. The absolute priority has been to manage the stress on the NHS which was already at its limits because of normal winter pressures before the Covid-19 epidemic got going. The delays in introducing the Lockdown, and the total inability of the government to engage with what had to be done (sourcing ventilators, PPE etc.) have further increased the pressures on the NHS. Even now the scandalous lack of PPE for frontline staff in hospitals and care homes is extraordinary and unforgivable.

We probably have little time to manage this critical situation. At present the Lockdown consists of the government giving highly simplified instructions to the population (wash your hands, stay-at-home, maintain social distancing, minimal journeys outside the home except for exercise, essential shopping and medical). Simply, the government is saying that if we do that then we will minimise the number of Covid-19 cases. We are all being told what to do by the government. Unfortunately this approach means that it is the young who are most unlikely to suffer from the disease and can least afford that their lives been put on hold. They are being forced into Lockdown in order to minimise the risks to the elderly and those less likely to be able to survive the virus.

A radically different approach is to turn the responsibility away from the state to the individual. Saying to everyone that each of us must take responsibility to make sure we do not catch the bug. Those most at risk need to stick rigidly to the most rigourous form of self isolation. Others must take responsibility for themselves and the people they live with. If you want to be as sure as possible you are safe while being at work then you need to wear of proper facemask (not one of those pathetic pieces of paper with two rubber bands, but a proper one that fits over your nose and mouth) and gloves. Once you are back home you need to wash your hands carefully and keep the facemask and gloves separate and secure. If you have vulnerable older people in the household you will have to be particularly careful to make sure you do not bring the bug in to them. Younger people living on their own or with other young people can be much more relaxed but they must be careful to stay at home if they show any of the symptoms, until they have recovered properly.

It is highly likely you won’t be able to buy a proper facemask anyway, but even using a scarf that wraps completely around your mouth and nose will go a long way towards giving you protection. It should be possible to design simple fabric-based masks that will give a good level of protection and can be made available quickly and cheaply.

The new self-tracking contact-tracing infection App announced by Matt Hancock on Sunday will be particularly useful and important to make this work well. He did not say when it might be ready but the phrases he used suggest that it might be three or four weeks before it is actually up and running.

It is essential that most of the British economy is restarted as soon as possible. By ensuring that everyone understands the way individuals are now responsible for doing the right thing to keep themselves and their families safe and well. This means that the present Lockdown must be substantially ended as soon as possible, and by that I mean at most a few weeks. All businesses should be able to reopen with a requirement on them that they look after the health of the employees, anybody working with them and any customers or other visitors who come into their premises. Employers must make sure that employees are provided with face masks and gloves, for example, and given enough space to feel comfortable and safe while at work. Employers would deem themselves to be unable to comply should simply be told to close until they can. All schools should reopen after the May half term in early June. Here teachers will need to ensure that they are adequately protected from infection to any of the children have the disease.

Other restrictions may be necessary. Social distancing will probably need to be maintained as much as we can tolerate. Everyone using public transport should be required to wear a face mask.

It is difficult to have much confidence in the way that this epidemic will pan out. Initially it just looked as if it was a matter of managing a rather nasty disease, significantly more fatal than the seasonal influenza we had become able to manage. Unfortunately what we also have is a substantial economic collapse that will affect individuals disproportionately at the poorest end of the scale and those that have the least resilience to manage the significant downturn in income that so many are experiencing. The government are undoubtedly culpable here to a dreadful degree and they must be held to account.

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