Covid-19 in UK

[jack]

ETA: There are a bunch of corrections in comments here and on FB, I don't have time yet to try to update the post interactively.

I have a lot of thoughts and emotions and the situation keeps changing so I can't really do an overview, so I'm just going to try to pour out what's in my head at the moment.

In Italy, the whole country is in lockdown. I'm not sure exactly what that means in practice. I think it means everyone is highly encouraged to stay inside except for medical work and food deliveries. But I don't know if the rules are bent a lot more some places than others. Some places have permits to go out, although it sounded like enforcement varied.

I know some people are basically just bored, waiting for it blow over. But I know some (few? many? all?) hospitals are at the point of *only* treating otherwise healthy people under 65, and being forced to let others die.

The UK is on trajectory to be at the same point Italy is now, in two weeks time. Unless the government orders a lockdown now. But in fact, their stated strategy is the opposite, to let it get WORSE than Italy is now, to let a majority of the population catch Covid, so that we're not at risk of relaxing lockdown, and then having another wave of infection start spreading again after.

If that's what's to happen, that means a gamble that the UK deliberately court a situation WORSE than Italy and China are in now, in order to avoid problems they think those countries are GOING to have in a few months of maintaining lockdown for years or courting repeated waves of infection. Am I misreading this??

And also a gamble that the virus won't mutate. And that a vaccine won't arrive in time to help. Which both are likely, but for from known, and not clearly explained by our government's announcements.

What would I do if I were in charge?

I really don't know. I would ask an epidemiologist. It sounds like the government DID ask an epidemiologist. It sounds like this plan came from scientists not politicians. But some people are like, "makes sense", and some people are like, "this is unforgivable". Why so much difference of opinion from people I'd like to trust? Does it depend what you've already accepted as unavoidable?

If I were in charge, I would have lock downs of cities where infections are known, and be clear what the risk in different areas was. I would pour resources into keeping deliveries and essential work, especially caring and medical work, going without risking infection (e.g. forced paid leave for anyone ill, blanket education about avoiding spreading disease and supplies, disinfectant everywhere and clear protocols for what you need to do). I would endorse plans which are happening anyway, like public awareness campaigns "if you're caring for a relative not in your house, drop off supplies and teach them how to use video chat, avoid visits wherever possible."

That slows down the spread, time to develop better treatments, time to produce more tests. I would follow China and WHO and gamble on eradicating it. Including preparing for testing everyone who flies in. I know there's a risk that's not possible and we need to go through "everyone catches it" anyway. But that's a guess, I don't actually know that strategy is best.

What do I think about the government's plan?

It's hard to know what the government is planning or going to do because they don't communicate clearly. A semi-official disclosure to a journalist says they're going to advise complete isolation for anyone over 70. They didn't mention younger but vulnerable people. They talked about "war-footing" isolation of nursing homes. The word "force" was used (?) Do they have a clear plan with resources they just are announcing slowly? Did they have good evidence that more clear communication would lead to premature panic? Are they making it up as they go? Do they not care? The truth is probably somewhere between.

On Thursday they talked about letting the disease spread to 60-80% of the population to get herd immunity. On Friday they talked about this plan for vulnerable people. They ARE taking that seriously. "War-footing" is the level of seriousness which is appropriate. But are they actually acting seriously or just going to issue a lot of useless announcements saying "don't catch it" with no actionable advice or help? It could be either. If they have useful, practical actions (e.g. specific advice for people who are vulnerable, specific action plan for nursing homes that's realistic, not fake) early next week, I'll feel a lot better. If not, I'm still quite worried.

Even if they're right that letting it spread through most of the population is necessary, if they actually intend to help the most vulnerable 10-20% of the population -- for whom it is likely deadly -- avoid it, they should be doing that NOW. It sounds like they do have a plan for what to do when, but when they don't announce any timelines it's really hard to know :(

What am I doing?

Slowing the infection rate is useful. Up till now I've been acting as normal. There's another week or so when I will avoid crowds, gatherings and intercity travel, but continue to go out to shop, to see people one on one. I'm washing hands regularly. Avoiding surfaces. Trying to avoid touching my face when I'm out. Basically not things that keep yourself safe, but things that mean if you're infectious but not symptomatic, you're less likely to spread it to others. Going out for a walk/cycle/drive away from people is probably ok.

There's no point pre-emptively isolating myself if other people aren't. So I will stay at that level of caution until society catches up with it. I will aim to reduce face to face contact except for close family. But if the government goes ahead with "let most people catch it", I will probably just expect that eventually I will catch it. I'm not that worried about me. Most otherwise healthy people have a mild case, and I will just pray that I'm not in the small proportion who need a hospital.

If schools stay open and there's no way for most people to avoid going to work then obviously there's not much to be gained by being much more cautious individually.

Mostly I'm aiming to work out what's sensible to do collectively. I'm not that worried for myself. A bit for Liv. Probably I will at worst just have a bad cough for a week. And even if the numbers were as bad as "1% of healthy people die" (hopefully not?) I would still just continue my life and hope for the best. But I'm trying to be realistic -- not optimistic not pessimistic -- about what to expect.

If I was over 70 or already had a medical condition, I would aim to avoid face to face contact entirely for three months. Getting food delivered. Video chat. Going for walks but not where people are. I feel silly and alarmist saying that. But that sounds like the only sensible decision. [ETA: Think in terms of, if in two months time 50%-100% of the people you know have a deadly disease, can you avoid catching it :( ] I know most people are only slowly adjusting to this idea.

Except maybe if you're in the healthier half of 70 yo, you don't need to, and if you're a 50 yo with a heart condition you do need to. I haven't seen advice here.

If I was in a household with a mix of those categories... I'm not sure what I'd do.

The situation may change entirely tomorrow. Or I may decide that that caution is futile. I don't know.

I went through a lot of worry working this out. Hopefully once I've decided I will just carry on: when I'm not trying to re-decide a decision all the time I'm usually ok just coping with a situation.

What I expect

I deleted a longer thing here. In two weeks, the UK will look like Italy is now, unless we take significantly different decisions than they have. Whether it's isolation or hospitals getting overwhelmed or (touch wood) heroic efforts paying off somehow, it will go on for months. Fingers crossed.

Scary numbers

If infections grow at the rate in Italy, I think that's something like, doubling every two days. Hopefully less with lockdown. More if people haven't taken any precautions at all. When you're thinking "should I hold that event in two weeks", think, in two weeks the situation will be a hundred times more serious. In a month it might be 10,000 times more serious. Maybe the situation will be better than that. But it will be better only if specific steps are taken to make it better, that weren't already taken in Italy.

I really hope my "off the internet" numbers are wrong and the government's plan is right and the sense of "oh, it won't be that serious" is right.

Informally looking at graphs, it looks like the death rate is 0.2% for young-ish otherwise healthy people. And 10-20% for people over 60 or 70. That's probably not directly age, but reflecting how many people in those categories already have weaker immune systems or hearts, etc.

But the hospitalisation rate is probably ten times the death rate, or more. Many of whom need ICU or ventilation or I'm not thinking about this bit too closely. And if the hospital gets overwhelmed, probably everyone who needs hospitalisation dies. It sounds like this is the point some areas in Italy are. They're treating mostly-healthy people who get a bad case of Covid. And giving up on anyone already vulnerable who catches it :(

If the government plan that 80% of people who expect to have mild symptoms or recover on their own catch it, and the other 20% DON'T catch it, that would be a death rate similar to that for under-50s. About 0.2%. With a hospitalisation rate, maybe 10x that? So nearly 10 in a 1000 of the UK needing hospitalisation over the next few months? But IIRC we only have 1 bed per 1000 people. Only a fraction of which are ICU beds.

And if actually, half of the 20% most vulnerable proportion catch it, they might all need hospital beds, another 10 bed per 1000 people needed.

Responses

This is all based off vague internet graphs. Several times over the last week I've changed my mind as I've learned something else I hadn't thought of.

People -- including epidemiologists', and other scientists I trust -- opinions seem very different. Sometimes it's "the government can be a bit useless, but basically they still have the best scientific advice". Other times it's anger at the lack of a prompt response to the first cases. Despite my lack of trust in the current government *in general* I am judging this response on its own merits. And I'm aware that most people's news is still from mainstream sources, so that maybe matters more than what I think.

Friends who know more about the science or medicine than me, PLEASE PLEASE correct those assumptions above. Both in theory and in what's plausible and what isn't.

Comments

[ewt]

I think that no matter what we do, this is going to be pretty bad. I think it's very easy in those circumstances to be angry. If we restrict movement and close schools, a lot of the economically vulnerable will be in real financial trouble; a lot of freelance musicians I know are already going to be struggling given the large number of cancellations of concerts and so on. If we continue as we are, we run the risk of a huge number of people dying. Either choice is going to make people angry, because both choices are basically horrible. (And, of course, the economically vulnerable are also likely to be more vulnerable in terms of physical health, for all kinds of reasons.)

I disagree with the government policy from Thursday, mostly because the data from e.g. South Korea suggests that it's possible to do better than Italy is managing, but only by much more intensive effort in terms of testing; and partly because the WHO has recommended more intensive measures than we currently have in place. Moving to less comprehensive testing seems to me to be unwise.

What I hope to see is that policy changing very, very quickly if the numbers don't suggest it is working. My lack of trust is not so much that I think the government is acting in bad faith or toward a bad outcome, but a certain amount of cynicism that they have the ability to change policy quickly enough.

[hairyears]

Let me give you the morbidity and mortality figures I have, from the WHO mission to China, for patients *outside Wuhan*.


Wuhan's a special case, and I'll discuss it at the end of this.

Firstly: how many people will get the disease, even mild or symptomless (but infectious) cases?

Chinese doctors and the WHO think it's *everyone*, or 95%, if the bug is circulating in the population at all. Anything short of a worldwide six-week 'Wuhan' total-lockdown means that the successful quarantines will be reinfected.

Eighty percent of those infected will have a mild or symptomless case, ranging up to "I feel awful but I'll still go to work if I can".

Twenty percent will get ill for real, with the kind of 'Serious Flu' that puts you on your back and off work for weeks. Or worse.

Five or six percent will require hospitalisation. Mostly, because they require treatment for secondary infections, but often because the primary infection is that bad.

Three percent will be 'critical': that means intensive care and a ventilator.

Within the critical fraction, one percent will die in China: they have halved the death rate by the use of oxygen perfusion machines, which oxygenate the blood outside the body.

That's the best news: now you get the bad news and the worst.

If you are in a less advanced country, like the United Kingdom, where those machines are so rare that they might as well not exist at all, that death rate will be two percent.

If attempts to slow transmission aren't as effective as China-outside-Wuhan, so that the case rate is above the available intensive-care capacity, all of the critical three percent will die.

If the hospitals are overwhelmed, a proportion of the cases requiring in-patient care will survive: call it three to five percent mortality.

Anywhere reporting a higher mortality rate probably has the wrong population divisor - they're only testing people with obvious symptoms. But see below for a nasty potential exception.

China-outside-Wuhan is a place where the case rate is going down, and staying well within the capacity of the heathcare system; this is achieved by testing, testing and testing.

Every case is identified and tested: their contacts are tracked down and isolated, and their social, familial, and economic circle comes into enhanced-hygeine and social-distancing.

Wherever testing shows that this approach is failing, and the infection rate is rising, increasingly-severe distancing and quarantining regimes are applied *well ahead of the time that large numbers of people are ill*, so that they do not need to take it as far as the Wuhan lockdown.

But they can do that, and they probably will need to in more than one city: but China will never see the 3% death rate again.


Note, also, that the Peoples Republic of China has - for most people, because not all people are considered 'people' - has taken care not to exceed the capacity of a social care system that protects the twenty percent of seriously-ill people from bankruptcy, destitution, eviction and starvation.

Some of the consumer goods you'll use today were made in factories where this does not apply: but, in principle, it does.

If you ever see an accurate death rate rise above five or six percent, anywhere, that's exactly what is happening: people are dying of being ill and poor, not of being severely ill.

Am I a fan of Chinese Communism? No. Among other things, I suspect that China-outside-Wuhan means 'China where we denuded the smaller towns and the countryside of medical resources' and "China, where certain people don't get count, and don't get treated".

Ugly, but there you are: there places uncomfortably close to home, wherever you're reading this, where racial and 'nationality' criteria are used to exclude identifiable segments of the population from treatment and social security.

Likewise, some people reading this will be from socially-backward countries where being too poor for treatment is a death sentence - whether for COVID-19, or for the diseases that are curable *for all* in an advanced society.

So... What's my point here?

Find me a country that's doing as much testing *and pre-emptive isolation* as China, and that'll be a country with the 2% death rate, and a rolling 5% of the workforce of the workforce off sick while the pandemic runs its course.

Find me a country with a death rate lower than 1% and it's either too early to tell, or they have replicated South Korea's remarkable success in isolating the elderly from contagion. That success will only persist if they can keep it up until a vaccine is available, or the virus ceases to circulate in the population.

Find me a country that isn't testing at all, and is waiting for the hospitals to collapse before imposing 'Wuhan' lockdowns, and you're probably showing me a humanitarian disaster.

The numbers where we are, and wherever you are, are somewhere between those two extremes.

[jack]

Thank you for those descriptions. That's hard reading, but is really useful knowledge.

[hairyears]

Do, please, reply to my comment again if you get better figures: they may go out of date as treatment improves, but I have only seen one credible contradiction.

That was from Washington State, where the eighty-twenty number was mild cases versus *hospitalisations* not 'bedridden and unable to work'. I followed that up, and the answers I got were "Everybody turns up to ER if they are too ill to work" and "the numbers are skewed, here, because of the initial outbreak was in a nursing home".

I'm treating that as an outlier and, while I suspect that there probably will be *something* unusual in the USA, I don't think that there are usable numbers available there, yet, even in Washington State.

Right now, I only have two population studies that are mature enough to be reliable, from countries that are actually handling this well - China and South Korea - and very sketchy statistics from emerging outbreaks in countries where it is being handled badly.

Nevertheless, it's worth watching those numbers evolve: climate, population density, general health, partial resistance, air pollution and smoking may well mean that different populations turn out differing statistics.

I would be very keen to see the figures for cities with NOX microparticulate pollution comparable to London; likewise, accurate figures for morbidity and mortality in patients with mild-to-moderate asthma managed by inhaled corticosteroids...

And the moon, with unicorns, and next week's winning lottery numbers, too.

One worrying anecdote - so far, two case histories in the USA - is of patients coming off the ventilator, making good progress to recovery, and then dying form heart failure.

This may or may not be observed elsewhere, and I'm not going through the WHO data again tonight: I mention it here to make a point that people with heart conditions need to start paying attention, the way I needed to, and then re-assess what they're doing as and when better data becomes available.

Waiting for certainty is lethally stupid, and only slightly less dangerous than working on uncorroborated data.

Face it, we're not going to get usable statistics from the United Kingdom at a time when they would be pre-emptively useful: watching what comes in from elsewhere, and guessing how much of it is applicable, is all we are going to get.

And I do not doubt that the disease still has some more surprises for us.

[jack]

I've not researched the figures, but what you posted accorded with what I'd put together from circulating diagrams that looked plausible and claimed to be based on situations like Wuhan, China, and the cruise ship where it was easy to measure. I am assuming something like that is true for now, but I will post if I learn anything.

[halojedha]

I've been feeling angry too. Planning to self isolate as soon as I get home tomorrow and trying to encourage others to do so too. I've been sharing that Medium post which I found convincing: https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca

And feeling angry about the cavalier approach of the UK govt which has left most people I talk to convinced they don't need to self isolate.

As I talk about this people have been sharing this post with me, which backs up the "herd immunity" policy https://personalpages.manchester.ac.uk/staff/thomas.house/blog/modelling-herd-immunity.html

So now I'm feeling confused about it all and not sure at all what to think.

[jack]

Thank you for those links. I'd seen both in passing but they made a lot more sense when contrasted against each other.

I'm not sure how to think of this. It feels like, putting those articles together, there's three different sorts of strategy. One is, lock down as early as you can, try to eliminate it. One is, get the spread as low as you can, even if it's still spreading, to keep hospitals from being overwhelmed. One is, to accept that 80% of people are going to catch it, and choose what to do to minimise the damage.

Several countries are trying #1, but may not be able to get it to 0, and may be reinfected even if they can. Some countries are trying #2, but may not have accepted it might take years. UK talked about aiming for #3 on purpose, but we may end there by default if we don't take action soon enough.

I think (???) article #1 is talking about aiming for case #1. Do everything you can to stop it as soon as you can. And if not, still keep it spreading as slowly as possible. Whereas article #3 isn't so much saying herd immunity is good, as inevitable, and saying, if it gets that bad, here's how to limit the damage. But I don't know which of those assumptions are right.

I'm sorry for working this out in a reply, maybe you didn't want to read it, but it's what put some of it together in my head for me. I am still trying to understand, because maybe it can be controlled if we actually try, or maybe it is more scary than I imagine because I can't look enough at the numbers.

[damerell]

"What do I think about the government's plan?"

I think the main worry here, for me, is whatever this government's plan is, I expect them to fuck it up, given that what we have is the Tory party purged of everyone who's unwilling to let the country burn rather than risk losing an election... being run by a Less Wrong cultist and a Prime Minister whose main merit over Trump is he can tell the same lie two days running.

The previous policy of inaction was obviously going to fuck things up, but this sudden swerve to performative authoritarianism - they'll fuck that up, too. It's an obvious false dichotomy, but we'd be better off with Thatcher in charge, God help us.