COVID-9 - A lack of joined-up thinking?
It is with some disquiet (understatement) that I find myself agreeing with the words of both Donald Trump and ex Tory health minister Jeremy Hunt.
Trump recently attacked the WHO for it’s poor, early response to the COVID-19 pandemic. I feel he has some justification in doing so. I feel, however, that he should not have done so when he did as we are at a point where the whole world needs to pull together to defeat this virus. He also said he was going to stop the US funding of the WHO because of it’s response. This, for the same reason, was also a mistake. In addition to that, he was not seeking to change things anyway - he was simply trying to deflect criticism away from his own, also very poor, response to the pandemic.
My agreement with Hunt is based on his recent attack on the scientific, medical advice provided to the UK government via SAGE (the group of medical experts set up for this purpose). It is becoming clearer and clearer that this advice was seriously flawed and that those experts were looking at an influenza outbreak rather than the much more lethal coronavirus that has struck the whole world and that this has resulted in many deaths - many of which could have been avoided if those experts had listened to the WHO, and considered all the other information already available, and advised accordingly.
What mistakes did the WHO make? Firstly, they seemed very slow to grasp the seriousness of what was happening in China. Then, when they did, they were still saying that there was no evidence that the virus passed from human to human. This I find difficult to comprehend. The spread of the virus suggested, even at an early stage, that human to human transmission was indeed taking place - unless there had been a vast increase in the consumption of infected animals. But if that was the case then how was the virus spreading to other countries? I am not aware of bats (or pangolins or whatever) taking flights to other countries while humans do. That would suggest that it was humans who were spreading the virus. By this time there were also reports from other countries now infected that human to human transfer was taking place. One example of this was from Taiwan - but Taiwan is, thanks to China, not a UN member and it looks like the WHO decided to ignore the reports from Taiwan - possibly because they feared upsetting China. Then there was our existing knowledge of coronaviruses. The common cold, what is wrongly often called the flu but is actually a corona virus and not influenza, SARS and Mers. All of those are coronaviruses and all spread from human to human. It strikes me that the WHO, rather than saying there was no evidence of human transmission, should have been saying that there is a strong possibility of human transmission. Maybe the WHO were trying to avoid a world wide panic - but maybe such a panic would have alerted governments around the world to take action a lot quicker? Their lack in this also, for me, indicates a lack of joined up thinking. If they had properly looked at all the points above, and put the evidence together, then they might have recognised sooner that human to human transmission was indeed happening and through this advised the world about the dangers far more quickly than it did.
When the WHO did eventually recognise the situation they did move faster to alert the World about what was happening. One of the main planks of their advice was to Test, Trace and Isolate (TTI). Good advice, but not every country took this advice on board (the UK being an example) The ones that did have, on the whole, done better at controlling the spread of the virus than the ones who didn’t. On the other hand they did not recommend the wearing of face protection by the general public. I find this difficult to comprehend as many of the countries, particularly in the far east, where the public do wear face protection (either by instruction or choice) seem to do better at restricting the spread of such viruses than the countries that don’t. In addition to that it seems to me that there seems to be a lack of joined up thinking in the WHO’s advice about this. To explain my thinking on this I need to outline some basic information that has come to light over the past couple of months;
1) It would appear that the amount of any virus (the load) picked up affects the severity of the infection: a light load might not even be noticed while a large load could well lead to a severe infection and, maybe, even death.
2) The ejection from a sneeze can travel about eight feet - and then hang about.
3) It’s thought that the infection can be easily picked up from a contaminated surface.
So, if you are not infected, and not wearing face protection, then someone infected, also not wearing face protection, who sneezes into your face from two feet away, will probably give you a serious doze of the virus. If, on the other hand, you are wearing face protection then, from that distance, you will probably still catch the virus - but the face protection could well reduce the load picked up. This might reduce the severity of the illness and maybe even save your life. If you are eight feet away, and not wearing face protection, then you could well still pick up a load large enough to make you very ill (or even still kill you). If, however, you are eight feet away, and wearing face protection, then surely the load picked up will be even further reduced? Keep in mind that over that eight feet the output from the sneeze will spread out reducing the amount of the virus hitting your face - and your face covering will reduce that load even further. Also, if you touch a contaminated surface and then, without thinking, touch your face you will be touching the outside of your mask and probably preventing the virus reaching your nose or mouth. So, while a face covering will not totally prevent you from becoming infected there will be a very good chance that any load picked up will not be as severe as would otherwise be the case.
So, while accepting that wearing face protection will not prevent you catching the virus, it seems to me that doing so could well reduce any load you do pick up. I also accept that extra care has to be taken in removing and disposing of a used face mask - but, for me, if someone has gone to the bother of wearing a face mask then they are also likely to be careful about removing and disposing of it and then following all other hygiene advice available. It strikes me that wearing face protection will help in reducing the chances of becoming infected or at least help in reducing the load you do get.
Many countries in Europe and elsewhere have now, despite WHO advice, moved to telling, or recommending, that their citizens wear face protection when it is impossible to adhere to social distancing guidelines (like in supermarkets or public transport). This is advised to prevent an infected person spreading the virus to those who are not infected. The advice is that someone not infected will get no benefit from wearing one. I would suggest that this under estimates, as outlined above, the extent to which a face mask will, at least, reduce the load that any uninfected person might pick up. There is also a downside to wearing a face mask if you are already infected. If a sneeze can infect someone eight feet away then it strikes me that sneezing into a mask will only increase the load of a person wearing a mask as that person will be taking back into themselves the load they would otherwise spread to others. The only way around this that I can see is for everyone to carry several face masks and change them if they start coughing or sneezing (and by also carrying a plastic bag and putting the sneezed into mask into that and closing the top to keep the bag sealed). Maybe this can be got around by folding a large tissue inside your face mask, carrying a supply of these and changing the tissue if you start to cough or sneeze - and putting the used tissue into the plastic bag? Of course, if someone does start coughing or sneezing then the best thing for them to do would be to get home as quickly as possible and self isolate for the recommended period - but to do that they might either have to complete their shopping trip (if that’s what they are doing) or starve!
Another area indicating a lack of joined up thinking is what has happened in care homes. I understand that care homes throughout Europe (and maybe the whole world) have experienced very high mortality rates but, since I don’t know what guidelines other countries were operating under, I will stick to what happened in the UK.
Firstly, early advice was that care home residents were in a safe bubble. That has turned out to be anything but the case. Why is the question. Consider the following;
1) From an early date it’s been known that the elderly were being hit hard by the virus.
2) It’s also been known, from an early date, that those with underlying health conditions were also being badly hit.
3) Care home residents are mainly the very elderly and often have underlying health conditions.
4) For far too long care home residents were still getting visitors.
5) Care home staff were out and about in the community, visiting supermarkets and often using public transport as, given their low pay, having their own transport was less likely than for the general population.
6) Care home staff either did not have PPE or suitable PPE.
7) Elderly folks were being moved into care homes, often from hospitals, without sufficient testing to ensure they did not have COVID-19.
All of the above, given a bit of joined up thinking, should have told our medical experts that the COVID-19 virus was not only going to get in to care homes but that the result of this would be avoidable deaths on a very large scale.
Another failure in joined up thinking, I would suggest, was the failure of the UK government to close our borders (airports and sea ports). The virus was spreading like wildfire around the globe but there was no attempt to prevent new cases reaching our shores. There was no testing at entry points and no isolation or quarantine periods imposed - people were free to come and go as they pleased - and many of those people arriving in the UK were highly likely to be carrying the virus. This, for me, was a bit like trying to blow out a camp fire while at the same time adding more wood to fuel the existing flames. A look at what Australia and, particularly, New Zealand did tells us what the UK should also have been doing.
With the infection rate (the R number) falling, the lockdown measures are being relaxed. I fear, however, that an R number between 0.5 and 0.9 (or even 0.8) is not sufficient on it’s own to prevent a second wave. I would guess that not only is a low R number required but that a robust TTI programme, which can deal with a second wave, is also required. People will still be catching this virus for a long time to come and without a TTI programme which can deal with this then a second wave becomes inevitable. On Monday the 18th of May, the Scottish First Minister, Nicola Sturgeon, indicated that the Scottish government, at least, was aware of this potential and that relaxing lockdown measures, to any great extent, would not be done until Scotland had a suitably robust TTI programme in place (TTIS in Scotland with the S standing for Support) - a programme which could respond quickly to the R number increasing again. Perhaps the Scottish government, at least, has found an expert who is able to employ joined up thinking?
It is, of course, easy to blame our governments for all those mistakes (and the UK government and the devolved administrations have made many mistakes) but in fairness many of those mistakes were due to the expert medical advice given by SAGE and CMO’s and health boards. I am not saying our medical experts have been idiots, and I’m sure they fully believed in the advice they were giving, but the advice, it would seem, has too often been woefully short of acceptable. The reason for that, I would argue, is that joined up thinking has been sadly lacking. I accept that hindsight is easy - but I would also argue that all of the above examples could have been avoided if a bit of joined up thinking had been employed as all the information was available before advice was given - if only someone had been able to look at all of it and join up the separate factors.
There is of course a historical problem which made matters worse in the UK. That was down to the Tory governments of the past ten years failing to fund the NHS properly. The reason for this was their ideological driven austerity programme. With more NHS spending during those ten years then the reduced cost now would have been more than enough to have made up for any spending made during those ten years. The UK has been woefully short of PPE and the ability to test, trace and isolate - and that has resulted in far more infections and deaths than would otherwise have been the case. In this the devolved administrations cannot be blamed as the UK spending on the NHS affects the budget those administrations receive: with their budgets reduced then there were simply not the funds to spend, which earlier NHS reviews indicated were badly needed.
Addendum - 26/05/2020
Further to the above post, the Andrew Marr show, on Sunday 24th May, included an interview with Sir Venkatraman (Venki) Ramakrishnan (I shall refer to him from here on as Sir Venki). The subject was about the wearing of face masks which Sir Venki had recently made a study of. Sir Venki is a highly respected biologist and is currently a member of the government’s SAGE team, having joined it only a few weeks ago. He is also the current president of The Royal Society and a Nobel prize winner.
I was pleased to hear him indicate that he fully supported the wearing of face masks. At the same time there were a couple of things he said that only confused me more than I already am.
He said there was no danger of an infected person making their illness worse after sneezing into their mask (by taking virus saturated droplets back into themselves). He provided two reasons for this. Firstly, the individual would already be loaded with the virus and taking more of it back in would make no difference. That’s fine but it would seem to contradict the theory that the amount of virus picked up seems to effect the severity of the illness experienced. The second reason he gave for this not being a problem was that the inside of the mask would trap the virus which would, therefore, not be taken back inside the wearer’s body, anyway. If that’s the case then that, surely, supports my view that wearing a face mask protects the wearer from catching the virus more than they are given credit for. I say this because Andrew Marr’s opening question repeated the view that wearing a mask prevented a wearer from spreading the virus as opposed to protecting the wearer from catching it. Sir Venki did not dispute that (therefore seeming to agree with this) while what he said would indicated otherwise. To be clear, if the inside of a mask can catch and hold on to any virus sneezed into it then surely a mask will also be able catch and hold onto any virus that it comes into contact with - preventing the wearer from catching it or, at least, reducing the load caught?
Trump recently attacked the WHO for it’s poor, early response to the COVID-19 pandemic. I feel he has some justification in doing so. I feel, however, that he should not have done so when he did as we are at a point where the whole world needs to pull together to defeat this virus. He also said he was going to stop the US funding of the WHO because of it’s response. This, for the same reason, was also a mistake. In addition to that, he was not seeking to change things anyway - he was simply trying to deflect criticism away from his own, also very poor, response to the pandemic.
My agreement with Hunt is based on his recent attack on the scientific, medical advice provided to the UK government via SAGE (the group of medical experts set up for this purpose). It is becoming clearer and clearer that this advice was seriously flawed and that those experts were looking at an influenza outbreak rather than the much more lethal coronavirus that has struck the whole world and that this has resulted in many deaths - many of which could have been avoided if those experts had listened to the WHO, and considered all the other information already available, and advised accordingly.
What mistakes did the WHO make? Firstly, they seemed very slow to grasp the seriousness of what was happening in China. Then, when they did, they were still saying that there was no evidence that the virus passed from human to human. This I find difficult to comprehend. The spread of the virus suggested, even at an early stage, that human to human transmission was indeed taking place - unless there had been a vast increase in the consumption of infected animals. But if that was the case then how was the virus spreading to other countries? I am not aware of bats (or pangolins or whatever) taking flights to other countries while humans do. That would suggest that it was humans who were spreading the virus. By this time there were also reports from other countries now infected that human to human transfer was taking place. One example of this was from Taiwan - but Taiwan is, thanks to China, not a UN member and it looks like the WHO decided to ignore the reports from Taiwan - possibly because they feared upsetting China. Then there was our existing knowledge of coronaviruses. The common cold, what is wrongly often called the flu but is actually a corona virus and not influenza, SARS and Mers. All of those are coronaviruses and all spread from human to human. It strikes me that the WHO, rather than saying there was no evidence of human transmission, should have been saying that there is a strong possibility of human transmission. Maybe the WHO were trying to avoid a world wide panic - but maybe such a panic would have alerted governments around the world to take action a lot quicker? Their lack in this also, for me, indicates a lack of joined up thinking. If they had properly looked at all the points above, and put the evidence together, then they might have recognised sooner that human to human transmission was indeed happening and through this advised the world about the dangers far more quickly than it did.
When the WHO did eventually recognise the situation they did move faster to alert the World about what was happening. One of the main planks of their advice was to Test, Trace and Isolate (TTI). Good advice, but not every country took this advice on board (the UK being an example) The ones that did have, on the whole, done better at controlling the spread of the virus than the ones who didn’t. On the other hand they did not recommend the wearing of face protection by the general public. I find this difficult to comprehend as many of the countries, particularly in the far east, where the public do wear face protection (either by instruction or choice) seem to do better at restricting the spread of such viruses than the countries that don’t. In addition to that it seems to me that there seems to be a lack of joined up thinking in the WHO’s advice about this. To explain my thinking on this I need to outline some basic information that has come to light over the past couple of months;
1) It would appear that the amount of any virus (the load) picked up affects the severity of the infection: a light load might not even be noticed while a large load could well lead to a severe infection and, maybe, even death.
2) The ejection from a sneeze can travel about eight feet - and then hang about.
3) It’s thought that the infection can be easily picked up from a contaminated surface.
So, if you are not infected, and not wearing face protection, then someone infected, also not wearing face protection, who sneezes into your face from two feet away, will probably give you a serious doze of the virus. If, on the other hand, you are wearing face protection then, from that distance, you will probably still catch the virus - but the face protection could well reduce the load picked up. This might reduce the severity of the illness and maybe even save your life. If you are eight feet away, and not wearing face protection, then you could well still pick up a load large enough to make you very ill (or even still kill you). If, however, you are eight feet away, and wearing face protection, then surely the load picked up will be even further reduced? Keep in mind that over that eight feet the output from the sneeze will spread out reducing the amount of the virus hitting your face - and your face covering will reduce that load even further. Also, if you touch a contaminated surface and then, without thinking, touch your face you will be touching the outside of your mask and probably preventing the virus reaching your nose or mouth. So, while a face covering will not totally prevent you from becoming infected there will be a very good chance that any load picked up will not be as severe as would otherwise be the case.
So, while accepting that wearing face protection will not prevent you catching the virus, it seems to me that doing so could well reduce any load you do pick up. I also accept that extra care has to be taken in removing and disposing of a used face mask - but, for me, if someone has gone to the bother of wearing a face mask then they are also likely to be careful about removing and disposing of it and then following all other hygiene advice available. It strikes me that wearing face protection will help in reducing the chances of becoming infected or at least help in reducing the load you do get.
Many countries in Europe and elsewhere have now, despite WHO advice, moved to telling, or recommending, that their citizens wear face protection when it is impossible to adhere to social distancing guidelines (like in supermarkets or public transport). This is advised to prevent an infected person spreading the virus to those who are not infected. The advice is that someone not infected will get no benefit from wearing one. I would suggest that this under estimates, as outlined above, the extent to which a face mask will, at least, reduce the load that any uninfected person might pick up. There is also a downside to wearing a face mask if you are already infected. If a sneeze can infect someone eight feet away then it strikes me that sneezing into a mask will only increase the load of a person wearing a mask as that person will be taking back into themselves the load they would otherwise spread to others. The only way around this that I can see is for everyone to carry several face masks and change them if they start coughing or sneezing (and by also carrying a plastic bag and putting the sneezed into mask into that and closing the top to keep the bag sealed). Maybe this can be got around by folding a large tissue inside your face mask, carrying a supply of these and changing the tissue if you start to cough or sneeze - and putting the used tissue into the plastic bag? Of course, if someone does start coughing or sneezing then the best thing for them to do would be to get home as quickly as possible and self isolate for the recommended period - but to do that they might either have to complete their shopping trip (if that’s what they are doing) or starve!
Another area indicating a lack of joined up thinking is what has happened in care homes. I understand that care homes throughout Europe (and maybe the whole world) have experienced very high mortality rates but, since I don’t know what guidelines other countries were operating under, I will stick to what happened in the UK.
Firstly, early advice was that care home residents were in a safe bubble. That has turned out to be anything but the case. Why is the question. Consider the following;
1) From an early date it’s been known that the elderly were being hit hard by the virus.
2) It’s also been known, from an early date, that those with underlying health conditions were also being badly hit.
3) Care home residents are mainly the very elderly and often have underlying health conditions.
4) For far too long care home residents were still getting visitors.
5) Care home staff were out and about in the community, visiting supermarkets and often using public transport as, given their low pay, having their own transport was less likely than for the general population.
6) Care home staff either did not have PPE or suitable PPE.
7) Elderly folks were being moved into care homes, often from hospitals, without sufficient testing to ensure they did not have COVID-19.
All of the above, given a bit of joined up thinking, should have told our medical experts that the COVID-19 virus was not only going to get in to care homes but that the result of this would be avoidable deaths on a very large scale.
Another failure in joined up thinking, I would suggest, was the failure of the UK government to close our borders (airports and sea ports). The virus was spreading like wildfire around the globe but there was no attempt to prevent new cases reaching our shores. There was no testing at entry points and no isolation or quarantine periods imposed - people were free to come and go as they pleased - and many of those people arriving in the UK were highly likely to be carrying the virus. This, for me, was a bit like trying to blow out a camp fire while at the same time adding more wood to fuel the existing flames. A look at what Australia and, particularly, New Zealand did tells us what the UK should also have been doing.
With the infection rate (the R number) falling, the lockdown measures are being relaxed. I fear, however, that an R number between 0.5 and 0.9 (or even 0.8) is not sufficient on it’s own to prevent a second wave. I would guess that not only is a low R number required but that a robust TTI programme, which can deal with a second wave, is also required. People will still be catching this virus for a long time to come and without a TTI programme which can deal with this then a second wave becomes inevitable. On Monday the 18th of May, the Scottish First Minister, Nicola Sturgeon, indicated that the Scottish government, at least, was aware of this potential and that relaxing lockdown measures, to any great extent, would not be done until Scotland had a suitably robust TTI programme in place (TTIS in Scotland with the S standing for Support) - a programme which could respond quickly to the R number increasing again. Perhaps the Scottish government, at least, has found an expert who is able to employ joined up thinking?
It is, of course, easy to blame our governments for all those mistakes (and the UK government and the devolved administrations have made many mistakes) but in fairness many of those mistakes were due to the expert medical advice given by SAGE and CMO’s and health boards. I am not saying our medical experts have been idiots, and I’m sure they fully believed in the advice they were giving, but the advice, it would seem, has too often been woefully short of acceptable. The reason for that, I would argue, is that joined up thinking has been sadly lacking. I accept that hindsight is easy - but I would also argue that all of the above examples could have been avoided if a bit of joined up thinking had been employed as all the information was available before advice was given - if only someone had been able to look at all of it and join up the separate factors.
There is of course a historical problem which made matters worse in the UK. That was down to the Tory governments of the past ten years failing to fund the NHS properly. The reason for this was their ideological driven austerity programme. With more NHS spending during those ten years then the reduced cost now would have been more than enough to have made up for any spending made during those ten years. The UK has been woefully short of PPE and the ability to test, trace and isolate - and that has resulted in far more infections and deaths than would otherwise have been the case. In this the devolved administrations cannot be blamed as the UK spending on the NHS affects the budget those administrations receive: with their budgets reduced then there were simply not the funds to spend, which earlier NHS reviews indicated were badly needed.
Addendum - 26/05/2020
Further to the above post, the Andrew Marr show, on Sunday 24th May, included an interview with Sir Venkatraman (Venki) Ramakrishnan (I shall refer to him from here on as Sir Venki). The subject was about the wearing of face masks which Sir Venki had recently made a study of. Sir Venki is a highly respected biologist and is currently a member of the government’s SAGE team, having joined it only a few weeks ago. He is also the current president of The Royal Society and a Nobel prize winner.
I was pleased to hear him indicate that he fully supported the wearing of face masks. At the same time there were a couple of things he said that only confused me more than I already am.
He said there was no danger of an infected person making their illness worse after sneezing into their mask (by taking virus saturated droplets back into themselves). He provided two reasons for this. Firstly, the individual would already be loaded with the virus and taking more of it back in would make no difference. That’s fine but it would seem to contradict the theory that the amount of virus picked up seems to effect the severity of the illness experienced. The second reason he gave for this not being a problem was that the inside of the mask would trap the virus which would, therefore, not be taken back inside the wearer’s body, anyway. If that’s the case then that, surely, supports my view that wearing a face mask protects the wearer from catching the virus more than they are given credit for. I say this because Andrew Marr’s opening question repeated the view that wearing a mask prevented a wearer from spreading the virus as opposed to protecting the wearer from catching it. Sir Venki did not dispute that (therefore seeming to agree with this) while what he said would indicated otherwise. To be clear, if the inside of a mask can catch and hold on to any virus sneezed into it then surely a mask will also be able catch and hold onto any virus that it comes into contact with - preventing the wearer from catching it or, at least, reducing the load caught?
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