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This has been the year of counting the days.
On Saturday morning people in England were preparing for a family Christmas. By 5 pm that afternoon they were phoning their regrets, in sadness and sometimes rage. All this may be good news. Opinions differ.
The story so far is that the United Kingdom has not had a good Corona war. While not as bad as Belgium, it is among the Terrible 20 nations who have seen over 700 per million deaths. Whatever the excuses (direct flights from Wuhan, many direct flights from everywhere, many older folk) there is a feeling that we could and should have done better. The coronavirus set us an IQ test, and exactly as our measures of global IQ would have predicted, the Chinese, Japanese, Taiwanese, Koreans and Singaporeans have done better than the Europeans. (That aside, I doubt if the final tally of deaths will be well predicted by national IQ. All that can be worked out later).
At the moment, blaming governments seems a justified reaction. They are supposed to protect us from bad stuff, in return for the taxes we pay them. In theory, they should have protected us better than we could have protected ourselves. Citizens have complained: They did too little too late; they did too much too soon; they did not get anything just right, just at the right time, and there is no health in them. Governments dare not reply: too many of you indulge yourself too much, have let yourself fall into a rotten state of health, and are slow to take up the advice about healthy living we have been offering you, so you are being justly punished. In fact, obesity and general sloth aside, the UK and the USA have a high uptake of flu vaccinations, so the populations played their part in protecting themselves, though they certainly overdid the cream cakes.
Back to England. Up till Saturday we had been released from lockdown into 3 Tiers of relative severity. If lockdown is the jail sentence, then the Tiers are the parole conditions. Starting Sunday a Tier 4 was declared, because the citizens of Kent and East London boroughs have been showing a rapid increase in cases (defined as positive test results, and increasing positive proportions of all people tested in that area). This has not yet been translated into hospitalisation and deaths, but that is presumed to happen in 28 days.
About a third of the population is under severe restriction, and will celebrate Christmas without all their family, and possibly on their own. The increase in these areas may be due to them being relatively poorer, and thus more likely to have public-facing occupations which require them to serve customers and use public transport. Another possibility is that the new mutant version is far more contagious (about 70% more) and that is driving the increase. This was the interpretation the government chose. It is the more prudent and cautious one, though it also gives them an additional excuse for a late change in policy. If cases are going up for whatever reason as we go into winter, then additional restrictions are probably required anyway. “Mutation” is a resonant word. “New, more contagious variant” is more accurate, based on what we know so far.
There is the further artefact that the better a country is at sequencing variants, the more variants they will find, and the more other countries will ban flights from the country with the variants. Interesting how things have changed. In the first months of the year, banning flights from Wuhan was seen as unnecessary by some experts (the virus will get here “anyway”) and simply unfriendly. Now, countries have no hesitation in taking appropriate health measures, though they may be hurting livelihoods and thus possibly lives, while trying to save lives.
The Pfizer vaccine has been given to at least 135,000 citizens, so they will have received partial protection (perhaps 50%, thus cutting their risk in half, which on its own is acceptable for a vaccine), and fuller protection (say another 40% for a total of 90%) a week after their 21-day booster jab. Currently, people over 80 years of age are already being vaccinated. They get about 5 days warning of their appointment, which for Londoners are delivered at specified specialist vaccination centres. The estimated date of vaccination for the 80 down to 75 year olds is January. There are 6 million people to vaccinate before they can start on the 75 year olds. People are called in in age order. All these dates depend on steady supplies of the vaccine, and on 20% of those offered the vaccine turning it down.
An interesting moral dilemma: should one encourage those most vulnerable to get vaccinated for their own good, or be grateful that they are getting out of the way and speeding up the protection one seeks personally? The vaccinators have already found out that instead of the official 5 doses, they can get 6 doses out of each phial. That means they had some left over, and so call in hospital doctors to take up those doses. Pragmatic, and probably with a greater effectiveness. If you vaccinate the 12% most prone to get the virus and spread it, you will get about 60% of the overall reduction conferred by vaccinations. We should track down those who meet most strangers, and vaccinate them first. Hospital porters, hospital receptionists, ambulance workers, security guards, and all those with gregarious, altruistic or promiscuous tendencies.
That is the general picture, but the fine detail is contradictory. Hospitals are not all that full, but there is much talk of their whelm being over. Cases are up, deaths per case down. Some specialist Covid hospitals (Nightingales) are resolutely empty. Many general practices claim to have no clue as to what is going on, and suggest their patients stop phoning them with questions they can’t . The numbers needed to treat are about 20 vaccinated to prevent a care home death, and about 160 to prevent the death of a care home worker or an over 80-year old outside a care home. Frontline health workers and over 75-year olds will need achieve 350 vaccinated to prevent one death. For over 65-olds, 1000 vaccinated per death saved.
Our intelligence has been tested in two ways. First, working out what to do. Second, explaining that “what to do” in a way which encourages people to comply with it. The UK Tier system is intended to guide behaviour according to the risk in a geographic area. That might help, and should be easy to understand, but it introduces many anomalies, and generates disputes. Areas of the country aren’t of themselves risky. It is only that in that particular place lots of people have been indulging in risky behaviours. A higher order approach would be to enunciate a set of general principles: don’t inhale other people’s exhalations. For that reason, avoid crowds, enclosed places with other people in them, and particularly places where people are talking loudly, shouting or singing. Above all, don’t expose yourself to any such place for very long. If you have to go into those spaces, wear a mask. The key rule is: Avoid exhalations. As part of inculcating the general principles, people must understand that some activities are more dangerous than others, which is why going to a night club is more dangerous than talking a walk in the park.
In retrospect, the whole approach to vaccination has been anachronistic, because there is a good case to be made that the Moderna vaccine was available in January and could have been deployed from 24 February onwards. It took two days for a bright scientist to complete her mRNA design, and then it was ready to go into production.
It could have presented a rational wager for those most vulnerable: shall I willingly take a probably very small risk now, to avoid a higher risk of severe illness or death later? It pits the individual against Fate, making them responsible for the decision, and possibly irresponsible if they don’t. The vaccine they were taking was based on an entirely new approach (mRNA) which was highly likely to be safe, and reasonably likely to be effective. On balance, volunteers might have felt it was a very good prospect. If the most vulnerable volunteered then it would be relatively quick and easy to see if it was efficacious. Naturally, the vaccine should have been given without a control group. Control groups are so last year. By now we know what reactions are found in control groups. Data on the last few years of control group studies could be pooled to provide a base rate. Getting rid of control groups doubles the speed with which you learn things of interest, which is whether the vaccine works, and has bearable side-effects. All that matters is that the benefits considerably outweigh the unwanted effects. All you have to do is to continue to dole out the vaccine to volunteers who are willing to take it. No need for any other regulatory processes. It should be a personal decision.
The more people volunteer the more persuasive the evidence, and the faster community protection is achieved. We have a new weapon in the armoury. We can design vaccines in advance, and keep them on the shelf till they are needed for rapid deployment. The rollout is the test. All the traditional phases are dropped. For once, we might get vaccines when they are required, not a year later, when most of the vulnerable are dead.
If this can ever be agreed and acted upon, it offers us a good prospect for years to come.