Covid-19 Gambles

[JohnW2]

There are far too few fewers around.

I'm not sure that I'm in the mood for grammatical criticisms/discussions - and it's quite a long time to Friday

Kind Regards, John

 

[echoes]

No you're not - your asking us whether 'what they have been advocating is "proportionate" or "disproportionate" but, as I said, that is so subjective and undefinable as to be unhelpful. All one can really do is speculate how the overall effects may have deferred between different strategies.

I don't see the distinction, and I think you're avoiding what is a very difficult question. I've attempted to define some metrics to make it tangible in terms of economic, health and social damage. Very hard to quantify, but they are real nonetheless.

Surely any justification of potentially (and actually) harmful outcomes of a deliberate measure must take into account the issue of proportionality; otherwise how can they possibly be justified? A cartoon-ish example: Would burning down one's house to get rid of a wasps' nest be proportionate, however effective a means of wasp control that might be?

The only benefit, and indeed only purpose, of lockdown is to temporarily suppress infections. All other effects are unintended. Yet we know that those effects reach far beyond that narrow intention, and they are effects which we seek in normal times to minimise. Avoidance of this is irresponsible and negligent - having a hard-to-quantify problem is no excuse for dismissing it as 'unhelpful' and swerving away from it.

Quite. And I don't think that anyone can deny that 'doing nothing' would also have 'grave effects' - hence the need to discuss comparisons.

A straw man: nobody's suggested doing nothing.

It's nothing to do with any models, discredited or otherwise, it's just simple ('ballpark') arithmetic. The virus we initially experienced had an R0 of about 3.0, which translates to an HIT of about 67% (of 'totally immune' people). In the absence of any NPIs, the virus will have spread rapidly until at least 67% (undoubtedly more, since immunity in 'the immune' will not have been 'total') had been infected - let's say at least about 45 million. Mortality (CFR) in those early days was estimated as 1-2% (obviously difficult at the time, given the lack of knowledge of 'the denominator') - so maybe 450,000 - 900,000 deaths. However, with that number of cases in a relatively short period of time (probably only a few months), the NHS would, back then (and probably still today), only have been able to treat a small fraction, so mortality would undoubtedly been a fair bit higher than that.

You have made some

I see no speculation, and cannot see any scope for speculation except by really extreme 'deniers'. Could any sensible person possibly deny that implementing measures to reduce inter-personal contact/proximity will reduce the number of infections?

errors.
1) You have assumed that R0 is constant, which it is not, and therefore the rise in case numbers is not exponential (actually it is 'worse' than exponential at first, but becomes 'better' than exponential very quickly and tends toward linear before reaching a peak). The shape of your own graph from March 2020 should tell you that at a glance. It will also tell you that the rise in cases became more-or-less linear before lockdown. There was no discernible effect to the shape of that curve which can be attributed to lockdown. Your 'simple arithmetic' is just that - too simple.
2) You have assumed that no prior immunity existed - it did.
3) (Not sure about this one!) but have you conflated CFR with IFR? We know that IFR is heavily dependent on demography, region etc https://www.medrxiv.org/content/10.1101/2020.05.13.20101253v3, and also subject to 3 orders of magnitude difference between the least and most vulnerable. Your simple arithmetic does not take this into account.
4) Your simple arithmetic has produced an estimate of 450,000 to 900,000 deaths. This is even higher than the (in)famous modelling at the time which we know was a pessimistic, worse case scenario, and has been shown to be inaccurate.

I see no speculation, and cannot see any scope for speculation except by really extreme 'deniers'. Could any sensible person possibly deny that implementing measures to reduce inter-personal contact/proximity will reduce the number of infections?

I'm not denying that such a link exists, and it is highly plausible. It's up to you to show that it does in fact exist, and that any apparent correlation has a causal relationship. I'll even meet you at least half way: That it's very plausible that the reduction in mobility in the 2 weeks or so before lockdown had a significant effect in reducing R0, but that the effect of the stringent lockdown itself had a marginal additional effect. I can't prove that, and can't point to any deviation from trends on the March 2020 graph that would indicate such. But then neither can you with your plausible yet speculative causal association. It may be that we are both partly correct, and the effect was too gradual to show as a clear deviation.
But as I have been saying repeatedly, even if you could demonstrate such a link beyond doubt, most of your work is still ahead of you in demonstrating that the lockdown is the best overall strategy. But you repeatedly dismiss this as unhelpful speculation, so I suspect we're not going to get very far with that!

As an aside, I want to dissuade you again from using the term 'deniers'. It is a cheap trope used to associate those with whom you disagree with 'holocaust-deniers' (a term which you have already managed to shoe-horn into this discussion), and all that which entails from that contemptible view.

Once one has accepted that, everything else follows, with no need for any speculation - decreased infections leads to decreased hospitalisation because of Covid and hence reduced diversion of healthcare resources away from non-Covid activities. What is 'speculative' about any of that?

It makes good qualitative sense, as do my arguments about unintended consequences, and likewise is very difficult to quantify with accuracy, so there is speculation. I don't think we can avoid it.

 

[echoes]

No you're not - your asking us whether 'what they have been advocating is "proportionate" or "disproportionate" but, as I said, that is so subjective and undefinable as to be unhelpful. All one can really do is speculate how the overall effects may have deferred between different strategies.

I don't see the distinction, and I think you're avoiding what is a very difficult question. I've attempted to define some metrics to make it tangible in terms of economic, health and social damage. Very hard to quantify, but they are real nonetheless.

Surely any justification of potentially (and actually) harmful outcomes of a deliberate measure must take into account the issue of proportionality; otherwise how can they possibly be justified? A cartoon-ish example: Would burning down one's house to get rid of a wasps' nest be proportionate, however effective a means of wasp control that might be?

The only benefit, and indeed only purpose, of lockdown is to temporarily suppress infections. All other effects are unintended. Yet we know that those effects reach far beyond that narrow intention, and they are effects which we seek in normal times to minimise. Avoidance of this is irresponsible and negligent - having a hard-to-quantify problem is no excuse for dismissing it as 'unhelpful' and swerving away from it.

Quite. And I don't think that anyone can deny that 'doing nothing' would also have 'grave effects' - hence the need to discuss comparisons.

A straw man: nobody's suggested doing nothing.

It's nothing to do with any models, discredited or otherwise, it's just simple ('ballpark') arithmetic. The virus we initially experienced had an R0 of about 3.0, which translates to an HIT of about 67% (of 'totally immune' people). In the absence of any NPIs, the virus will have spread rapidly until at least 67% (undoubtedly more, since immunity in 'the immune' will not have been 'total') had been infected - let's say at least about 45 million. Mortality (CFR) in those early days was estimated as 1-2% (obviously difficult at the time, given the lack of knowledge of 'the denominator') - so maybe 450,000 - 900,000 deaths. However, with that number of cases in a relatively short period of time (probably only a few months), the NHS would, back then (and probably still today), only have been able to treat a small fraction, so mortality would undoubtedly been a fair bit higher than that.

You have made some errors.
1) You have assumed that R0 is constant, which it is not, and therefore the rise in case numbers is not exponential (actually it is 'worse' than exponential at first, but becomes 'better' than exponential very quickly and tends toward linear before reaching a peak). The shape of your own graph from March 2020 should tell you that at a glance. It will also tell you that the rise in cases became more-or-less linear before lockdown. There was no discernible effect to the shape of that curve which can be attributed to lockdown. Your 'simple arithmetic' is just that - too simple.
2) You have assumed that no prior immunity existed - it did.
3) (Not sure about this one!) but have you conflated CFR with IFR? We know that IFR is heavily dependent on demography, region etc https://www.medrxiv.org/content/10.1101/2020.05.13.20101253v3, and also subject to 3 orders of magnitude difference between the least and most vulnerable. Your simple arithmetic does not take this into account.
4) Your simple arithmetic has produced an estimate of 450,000 to 900,000 deaths. This is even higher than the (in)famous modelling at the time which we know was a pessimistic, worse case scenario, and has been shown to be inaccurate.

I see no speculation, and cannot see any scope for speculation except by really extreme 'deniers'. Could any sensible person possibly deny that implementing measures to reduce inter-personal contact/proximity will reduce the number of infections?

I'm not denying that such a link exists, and it is highly plausible. It's up to you to show that it does in fact exist, and that any apparent correlation has a causal relationship. I'll even meet you at least half way: That it's very plausible that the reduction in mobility in the 2 weeks or so before lockdown had a significant effect in reducing R0, but that the effect of the stringent lockdown itself had a marginal additional effect. I can't prove that, and can't point to any deviation from trends on the March 2020 graph that would indicate such. But then neither can you with your plausible yet speculative causal association. It may be that we are both partly correct, and the effect was too gradual to show as a clear deviation.
But as I have been saying repeatedly, even if you could demonstrate such a link beyond doubt, most of your work is still ahead of you in demonstrating that the lockdown is the best overall strategy. But you repeatedly dismiss this as unhelpful speculation, so I suspect we're not going to get very far with that!

As an aside, I want to dissuade you again from using the term 'deniers'. It is a cheap trope used to associate those with whom you disagree with 'holocaust-deniers' (a term which you have already managed to shoe-horn into this discussion), and all that which entails from that contemptible view.

Once one has accepted that, everything else follows, with no need for any speculation - decreased infections leads to decreased hospitalisation because of Covid and hence reduced diversion of healthcare resources away from non-Covid activities. What is 'speculative' about any of that?

It makes good qualitative sense, as do my arguments about unintended consequences, and likewise is very difficult to quantify with accuracy, so there is speculation. I don't think we can avoid it.

 

[SimonH2]

My view is that lockdown has turned a public health crisis into not only a public health crisis, but an economic crisis, an education crisis, a mental health crisis, a democratic crisis, a legal crisis and a moral crisis.

We cannot judge lockdown on sole criterion of suppressing Covid, even if it can be demonstrated that it had some limited effect (which is very much contested).

I've always thought it disproportionate, and I suspect we will learn just how much over the years to come.

As others have suggested, "doing nothing" would also have created those crises. John has suggested some figures indicating a likely death toll. I would suggest that had Boris stood up and suggested "we do nothing, carry on - but probably more than a million people will die and many more will be left incapacitated" then it would "not have gone down well" with the populations regardless of any individual's political leaning.
But apart from that, realistically, would the country have been able to "carry on" ? There's talk of this pingdemic that's now causing problems to businesses - with some now saying that they are struggling to stay open. Imagine if instead of contacts, they were actual cases - there'd be serious logistics problems from lack of able bodies drivers, production problems from lack of able bodied factory workers, shops closed due to lack of able bodied staff, schools closed due to lack of able bodied teachers ... And then people will realise that we wouldn't have an effective police force, so finding the shops closed and/or poorly stocked (remamber the great bog roll shortage ?), I suspect we'd see widespread looting. Then what, call out the army (if they can muster an able bodied response) to start shooting civilians. We're into "apocalypse film" territory very quickly.
Now, if you think that wouldn't represent a "an economic crisis, an education crisis, a mental health crisis, a democratic crisis, a legal crisis and a moral crisis" then I don't know what would.

Could things have been done differently ? Most definitely. But as said, we can't reset the world and have another go at the experiment, so all we can do is hypothesise about what may or may not have worked better.

And something else to bear in mind is that at the time, we simply didn't know how bad it was or how to even treat the symptoms. What we did know from very early on was that it spread worse than flu by virtue of being transmissible before symptoms appeared - which rules out any form of "at the first hint of ... stay at home" as an intervention, by the time any symptoms appear it's too late for that. And we knew that the mortality rate was significant. So a reasonable assumption would have been that the death toll from doing nothing could easily have been "several million".
In that context, I don't think doing nothing would have been a defendable proposal.

<graph of vaccine uptake rates>

It's unfortunate the way they've drawn that in that it explicitly hides what would have been interesting to look at. As best I can see it (I'm partially colour blond so struggle matching the key to the lines), it looks like the younger group had a slow start AFTER reaching 15% uptake. I suspect that had the graph been drawn with the zero time reference as "when that group was first offered the vaccine" then we'd see the younger groups lagging massively in uptake compared to the older groups (i.e. there being a long and slow climb to even reach that 15% compared with a quick uptake in older groups).
That's my "hunch" based on observation that older people tend to realise the value of vaccines and the threat to ourselves of not having it - while younger people (wild generalisation alert) tend not to, and also tend to have a sense of invulnerability.

And nobody's yet tried to argue that lockdown is a sustainable and proportionate measure, given that they have effects far beyond suppression of a virus.

I don't think anyone has tried to argue that lockdowns are sustainable - far from it. For those, like myself, who think it was the right thing to do, it's a case of them having been "less bad" overall than the alternatives. And lets be honest here - it's all about trying to find the "least bad" choices from a number of very bad options.

I don't have to postulate an alternative.

Well actually, if you are arguing that lockdowns were "wrong", then you need to postulate what would have been less bad. Otherwise you are no better than the points scoring politicians who, safe in the knowledge that they don't have to deliver from the opposition benches, just criticise those who are having to make truly horrendous choices.

... and for a disease which is no more dangerous for the majority of the population than seasonal flu.

Really ?
That's one of those things that many people spout - while it is clearly not the case. Many more have died "from Covid" than would normally die from seasonal flu - even with all the mitigations/interventions we've had. Yes, lots of people die from flu, and going forward, lots of people will die from Covid. But short of wild new variants (e.g. the Spanish Flu pandemic), I don't see flu being anything like Covid.
And when was the last time you heard of "long flu" ?

 

[echoes]

If I removed all the time-series labels from this graph, and the key, and asked you to state which line was associated with stringent lockdowns, which would you choose?
Which country "flattened the curve" to best effect?

 

[echoes]

Seems its what an awful lot of Swedish scientists are doing to try and work out why what happened in Sweden occurred, but of course I'll make sure to let them know that you disagree with the approach

Well you could save them all the time and effort, since you already have all the answers. I'm sure that half the deaths in care homes have nothing whatsoever to do with it. https://www.euronews.com/2020/11/25...rement-homes-under-fire-over-coronavirus-care

(https://www.news-medical.net/news/2...d-Norway-before-and-after-COVID-pandemic.aspx)
"Our study shows that all-cause mortality was largely unchanged during the epidemic as compared to the previous four years in Norway and Sweden, two countries which employed very different strategies against the epidemic," emphasize study authors in this medRxiv paper.

In other words, excess mortality from COVID-19 may be less conspicuous than previously perceived in Sweden, while mortality displacement may be used to explain at least part of the observed findings.

More specifically, mortality displacement implies temporarily increased mortality (i.e., excess mortality) in a certain population as a result of external events, which likely arises because individuals in vulnerable groups die weeks or months earlier than they would otherwise – primarily due to the timing or severity of the unusual external event. The excess mortality is, thus, predated or followed by time periods of lower than expected mortality."

 

[JohnW2]

I don't see the distinction, and I think you're avoiding what is a very difficult question. I've attempted to define some metrics to make it tangible in terms of economic, health and social damage. Very hard to quantify, but they are real nonetheless.

I think I may soon have to draw a line under this aspect of the discussion, since I am far more concerned about what happens as we move forward to the present than in having discussions about strong polarised views about what has happened, and what 'could have happened'. The NPIs we've had are history, and can be debatedin the future. In terms of the present and immediate future, the most I have been really suggesting is that it would have probably been better to retain the last (few) remaining NPIs for a few more weeks.

Anyway, as for the above, I'm 'avoiding' your question, not because it is difficult but because, for me, it is impossible. For example, I haven't a clue as to how many deaths should be considered 'proportionate' to any particular degree of, say, economic, educational, sociological or whatever harm

Surely any justification of potentially (and actually) harmful outcomes of a deliberate measure must take into account the issue of proportionality; otherwise how can they possibly be justified?

It would be nice but, as above, at least for me, deciding what would be 'proportionate' (in the present context) is impossible.

You have made some errors. ... 1) You have assumed that R0 is constant ... 2) You have assumed that no prior immunity existed - it did. ... 3) ... have you conflated CFR with IFR? .... 4) Your simple arithmetic has produced an estimate of 450,000 to 900,000 deaths. This is even higher than the (in)famous modelling at the time which we know was a pessimistic, worse case scenario, and has been shown to be inaccurate.

I would suggest that you're clutching at straws by raising all those points of detail. Forget those issues and, indeed, forget all the numbers. If you don't agree that, in the absence of any NPIs, a "very large" number of people would have died in a relatively short period of time, rendering the NHS unable to treat anything other than Covid (unless they decided not to attempt to treat Covid infections, in which case there would be even more deaths), then I really don't see that there is much scope for intelligent discussion between us.

I'm not denying that such a link exists, and it is highly plausible. It's up to you to show that it does in fact exist, and that any apparent correlation has a causal relationship. I'll even meet you at least half way: That it's very plausible that the reduction in mobility in the 2 weeks or so before lockdown had a significant effect in reducing R0, but that the effect of the stringent lockdown itself had a marginal additional effect.

R0 doesn't (or shouldn't) change for a particular variant of a particular virus - since it is a measure of transmission of the virus in a totally susceptible (non-immune) population who are 'mixing totally freely', with no restrictions. It is the ';effective' reproduction number (R, Re or Rt) which will change as a result of changes in the susceptible (non-immune) population, formal 'NPIs' or 'informal' changes in behaviour of the population.

However, that technicality aside (I presume you meant R/Re/Rt), if I understand you correctly, in saying that you are only prepared to 'meet me half way', and that you think that reducing inter-personal contact/proximity only had a marginal effect in reducing the number of new cases (over and above that due to pre-lockdown changes in behaviour) then, again, I don't think there is anything further we can sensibly discuss.

As an aside, I want to dissuade you again from using the term 'deniers'. It is a cheap trope used to associate those with whom you disagree with 'holocaust-deniers' (a term which you have already managed to shoe-horn into this discussion), and all that which entails from that contemptible view.

OK. I'm quite prepared to consider substituting any any other term you would prefer.

It makes good qualitative sense, as do my arguments about unintended consequences, and likewise is very difficult to quantify with accuracy, so there is speculation. I don't think we can avoid it.

As I said, in the context I was discussing, there was nothing speculative. It is a simple fact that (unless the NHS had already decided 'not to treat patients with Covid infection), a reduced number of new infections means less diversion of NHS resources away from diagnosing/treating patients with non-Covid problems.

Kind Regards, John

 

[JohnW2]

If I removed all the time-series labels from this graph, and the key, and asked you to state which line was associated with stringent lockdowns, which would you choose? Which country "flattened the curve" to best effect?

I'm not sure what you mean by the 'time series labels' but, if there were no key, I would probably say (as I did) that (given all the uncertainties which exist), there was very little difference between the two curves. Anyone who tries to draw conclusions out of apparent differences (given all the uncertainties) would, again, in my opinion, be clutching at very tenuous straws.

Kind Regards, John

 

[Notch7]

therefore the rise in case numbers

I’m not sure how case numbers are much use…surely if you test more, you get more.

 

[mikeey84]

compared to the previous four years in Norway and Sweden,

Why are they cherry picking data from countries that just happen to be next door?

 

[echoes]

As others have suggested, "doing nothing" would also have created those crises.

Staw man: nobody's suggested doing nothing.

Could things have been done differently ? Most definitely. But as said, we can't reset the world and have another go at the experiment, so all we can do is hypothesise about what may or may not have worked better.

No argument with that. All we can do is look closely at what we now know. But there'll be another pandemic at some point, and I hope we can learn from this one: what to do and what not to do.

I don't think anyone has tried to argue that lockdowns are sustainable - far from it. For those, like myself, who think it was the right thing to do, it's a case of them having been "less bad" overall than the alternatives. And lets be honest here - it's all about trying to find the "least bad" choices from a number of very bad options.

Agree, but nobody else really has tried to even speculate about the unintended consequences. John thinks it's unhelpful speculation, but it will be real enough, and has been very real, and very horrible for a large number of people, many of whom are in much less fortunate domestic and career positions than us.

Well actually, if you are arguing that lockdowns were "wrong", then you need to postulate what would have been less bad. Otherwise you are no better than the points scoring politicians who, safe in the knowledge that they don't have to deliver from the opposition benches, just criticise those who are having to make truly horrendous choices.

But I did though: in the very next paragraph I suggested the published pandemic plan as a viable alternative.

That's one of those things that many people spout - while it is clearly not the case. Many more have died "from Covid" than would normally die from seasonal flu - even with all the mitigations/interventions we've had. Yes, lots of people die from flu, and going forward, lots of people will die from Covid. But short of wild new variants (e.g. the Spanish Flu pandemic), I don't see flu being anything like Covid.
And when was the last time you heard of "long flu" ?

I'm not seeking to diminish the severity of covid, but we must view it ion context of what can be expected from time to time.
Overall, if we take the figures at face value and assume a worst case, each Covid season has killed about twice as many people as a severe flu season, but tragically concentrated among the elderly, so I'm not seeking to diminish it.
Covid is less deadly to the young than flu. IFRs for healthy, under 60 yo's are very similar. In the elderly and vulnerable, it is up to 1000 times more deadly. I've stated that several times. And I did also state "for the majority of the population". I don't see how this is inaccurate.
I have heard of post-viral fatigue syndrome though. Is it distinct? Quite possibly, given that the viruses themselves are different. Interestingly (and anecdotally), I have a friend suffering from 'long covid' after quite a nasty infection - she has also suffered from M.E. extensively in the past.

 

[mikeey84]

Our study shows that all-cause mortality was largely unchanged during the epidemic as compared to the previous four years in Norway and Sweden, two countries which employed very different strategies against the epidemic," emphasize study authors in this medRxiv paper

This article is a preprint and has not been peer-reviewed. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

 

[echoes]

Why are they cherry picking data from countries that just happen to be next door?

Are you deliberately being obtuse, or just snarky? There's a difference in comparing 2 similar (in some ways) countries to find out what differences were actually at play (when those differences were more varied and nuanced than lockdown/no lockdown), to making an blunt association between severity of lockdown and decreased mortality.
As it goes, I don't believe that lockdown is the significant factor, as evidenced by the seemingly non-correlation of lockdown severity (and lockdowns are a very blunt instrument) across the world. Local effects and specific polices may make all the difference.
Maybe that study will usefully discover that specific mistakes were made in Sweden that were not made in Norway. Maybe that the Norwegian lockdown was unnecessary, but they did some important things right. I don't know - that's why I'm interested in making as any many comparisons as possible.

 

[mikeey84]

Are you deliberately being obtuse, or just snarky? There's a difference in comparing 2 similar (in some ways) countries to find out what differences were actually at play (when those differences were more varied and nuanced than lockdown/no lockdown), to making an blunt association between severity of lockdown and decreased mortality.
As it goes, I don't believe that lockdown is the significant factor, as evidenced by the seemingly non-correlation of lockdown severity (and lockdowns are a very blunt instrument) across the world. Local effects and specific polices may make all the difference.
Maybe that study will usefully discover that specific mistakes were made in Sweden that were not made in Norway. Maybe that the Norwegian lockdown was unnecessary, but they did some important things right. I don't know - that's why I'm interested in making as any many comparisons as possible.

I was pointing out that you previously criticised me comparing (or cherry picking data) very similar countries.

You then quoted a (non peer reviewed, rather flawed) study that does exactly that, for good reasons (as I listed earlier)

 

[JohnW2]

I’m not sure how case numbers are much use…surely if you test more, you get more.

They are certainly theoretically potentially useless for comparing countries - since, as you imply, they are so dependent upon how many tests are done, on whom and why. We see that dramatically in terms of the UK 'first wave', since the number of 'cases' then reported was quite probably an order of magnitude less than the truth, since we were primarily only testing the relatively 'small' number of patients who were ill enough with 'very probably Covid infection' to have been hospitalised.

Within a country, policies/practices as to 'how many tests are done, on whom and why' does not change all that much in the short- and medium-term (except when we do 'surge testing', which therefore can be misleading) - so the reported test results probably give a reasonable indication of short- and medium-term changes in the true number of cases.

As I said before, one might expect that 'Covid deaths' would be a much 'harder' metric, hence more suitable for comparing countries - but, as I've said, even that is not all that true because of appreciably varying definitions of 'a Covid-19 death' between, and even within, countries.

Kind Regards, John