The best intelligence items are usually those at the very end of the test, where only one or two percent of test takers will reach them. Of course, for the very bright these will be too easy, but standard tests are designed for us common folk, not the genius fringe. Facing the coronavirus, it is that smart fraction on whom we depend for survival. Will we pay the cost of losing at least 1% of our citizens, or can we manage ourselves intelligently to lower that rate?
The strategy taken by the UK government, somewhat different from other countries, is based on a paper “UK Influenza Pandemic Preparedness Strategy 2011” recommended to me by a reader, dearieme, and I have been reading it.
I have copied out some bits which caught my eye:
Ensure that we are able to detect the emergence of a new virus and its arrival in the UK as quickly as possible and to determine the severity of illness, age groups and populations most affected and how transmissible it is.
Modern mass global transit also affords opportunities for the virus to be rapidly spread across the world, even before it has been identified. The short incubation period of influenza means that within a relatively short period of time a significant number of cases will appear across the globe. It is likely to take at least four to six months after a novel virus has been identified and isolated for an effective pandemic influenza vaccine to become available from manufacturers. 2.12 This means that it almost certainly will not be possible to contain or eradicate a new virus in its country of origin or on arrival in the UK. The expectation must be that the virus will inevitably spread and that any local measures taken to disrupt or reduce the spread are likely to have very limited or partial success at a national level and cannot be relied on as a way to ‘buy time’.
It will not be possible to stop the spread of, or to eradicate, the pandemic influenza virus, either in the country of origin or in the UK, as it will spread too rapidly and too widely. From arrival in the UK, it will probably be a further one to two weeks until sporadic cases and small clusters of disease are occurring across the country. Initially, pandemic influenza activity in the UK may last for three to five months, depending on the season. There may be subsequent substantial activity weeks or months apart, even after the WHO has declared the pandemic to be over.
The plan envisages up to 50% of population getting infected, and 2.5% dying if there is no effective treatment. Assumptions are not predictions.
It is a carefully written document, based on the knowledge of the time, and with an good understanding of strategic choices to be made. The authors have an understandable wish to achieve proportionality: using measures which meet the severity of the threat and at the time at which they can have maximum effect.
In summary, it accepts that viral infections cannot be stopped (the bomber will always get through) and that measures taken must be proportionate in terms of costs and benefits in the broadest sense. It is a sensible document, but hardly a radical one.
As Greg Cochran has pointed out, the only way to defeat the virus is to lower its reproductive index below 1. Whilst more than one person gets the virus, even at an R0 of 1.3 we have a problem. Victory is to deny the virus its stepping stones. This simple fact highlights a paradox: stern measures work best when they appear to be unnecessary. Banning plane flights stops the spread globally, and works best when there is no need for it, because no cases have presented themselves. This requires the ability to conceive of future events, and plan to avoid them. It requires high intelligence, and even higher political courage.
A week ago, Uruguay had no cases. Why is this country worth talking about? Apart from personal reasons, it had kept itself virus free because at this time of year it is relatively little visited. Even in tourist season it has relatively few flights. It now has 4 cases, 3 of these visitors from Milan, 1 from Barcelona. Letting them fly in has created the possibility of an epidemic in a country thousands of miles away from the original focus of the disease. From Wuhan the virus got a lift to Milan, and now to Montevideo. In addition, friends tell me of a lady who trades in leather, well known in Milan, who on her second trip back (she already had a fever on her first trip a month ago) has reportedly been diagnosed after coming to a 500 person wedding in a suburb of Montevideo. These friends wonder if there was any surveillance of passengers arriving from Italy, and also wonder why she did not consult a doctor about her previous bout of fever. Today I find that Uruguay now has two new cases, and they had not traveled abroad, so they are autochthonous.
A remark by a UK scientific advisor has led people to believe that it is Government policy to rely on herd immunity. The best herd immunity is vaccination. Second best by far is people getting the disease and surviving it, which is called acquired immunity.
What the document says about herd immunity mostly refers to vaccination and the priority groups once a vaccine is ready. It does not appear to be a deliberate policy that people should get the disease, rather that there is no way of stopping it, in an open world. Now, however, countries are severely restricting air travel, closing the stable door after the horse has bolted.
If it is not possible to limit the spread by achieving herd immunity 21, where so many people are immune that the disease cannot continue to infect people to maintain itself in the population, it is important to reduce the impact of the pandemic.
They explain the concept:
The primary aim of vaccination is to protect the individual who receives the vaccine. Vaccinated individuals are also less likely to be a source of infection to others. This reduces the risk of unvaccinated individuals being exposed to infection. This means that individuals who are not vaccinated will still benefit from the routine vaccination programme. This concept is called population (or ‘herd’) immunity
So, where are we now with the UK response? The Government is trying to be as measured as possible, taking only those steps which they believe are proportional to the threat. They cannot follow Singapore, because it is already too late to do so. Until very recently, the airports have been open, all too open. The virus cannot travel, but airline passengers are ensuring that it gets to the next available host, wherever on earth it can be found.
The Government fears that instituting severe quarantine and social distancing now may be too soon, given that it must be sustained for about 4 months. This is a slightly odd argument, since as a rule of thumb prevention works best before the event, which in this case means before there are sufficient cases to warrant it. However, having given up avoiding getting the virus, they are now trying to manage the distribution of cases, prolonging the event but reducing peak cases so that health systems can just about manage them.
Absent a prompt vaccination or secure treatment method the aim is to hope that a substantial fraction of the population gets only minor symptoms, and then recovers with a good degree of acquired immunity, able to help manage basic services while the more vulnerable (usually the 70+ age range) are kept out of harm’s way as much as possible, and released out into the open only when the disease is on the wane.
So, like any general mustering insufficient forces against a much stronger enemy, the strategy is to keep some powder dry for when it is most needed.
The only time I tried to advise a Government was when I gave very occasional advice to the Prime Minister’s Policy Unit under Tony Blair. I told them that policies were of two sorts: instrumental and symbolic. Like them, I favoured the instrumental approach, based on the best available evidence. Sometimes, of course, politics being what it is, human nature leans towards the symbolic.
For example, the Government bravely argued that it was premature to close large public sporting events and meetings, because the main likely spread of disease was within a household. However, in making this argument they used a standard average figure for the number of people a carrier can infect. That is wrong, precisely because that average is based on people who, normally, don’t have a chance to interact with large crowds. For example, most of my meetings are with three or four people, but when I go to local community lectures roughly once a month I will probably greet 30 people, and interact with most of them after the lecture. If I were infectious I would have more chance of passing on the virus at the 30 people meeting than my usual 3 person meetings.
However, not banning public meetings is probably wrong from a symbolic point of view. Such closures are dramatic, and will drive home to people that the crisis is real, and that they had better concentrate on instrumental policies like social distancing generally, and more frequent hand washing.
A word about hoarding: the problem is that people do not hoard enough. In a just-in-time economy most kitchen cupboards a bare of essential foods. Societies would be more resilient if they had some rice, flour, pasta and a few tinned goods available, as farmer’s wives did in former times. The expenditure is minimal, the space required likewise, and 7 days worth of food would keep households more tranquil, and a little less likely to panic buy.
Meanwhile, self-isolation continues. It is very much like a standard winter mode of living, continued into early Spring. The streets are relatively deserted, so a bit of walking is always possible. Family doctors can no longer be visited in their surgeries: contact is only by phone. Pharmacies are very busy, and don’t always have the medicines required. Hospitals are to be avoided.
Compared to the Great Pestilence, this is a small affair.