Journal of the Plague Year IX – The Cloud of Unknowing

Lockdowns have been relaxed around the world. But, at a global level, the coronavirus pandemic is not only still with us but is intensifying. There are still major questions around the disease with which we are slowly learning to live, writes Victor Hill.

Global overview

As of this morning 26.5 million people around the world have been diagnosed with Covid-19 and 873,285 have been recorded as having died of the condition. Next week that mortality figure is likely to surpass the psychologically significant one million mark. The virus has been detected in nearly every country and territory on the planet.

The coronavirus is ebbing in many countries that have already been hit hard; but, that said, the number of new cases has been growing faster than ever due to increased testing, and has been running over the past week at over 200,000 cases per day. In a wide range of countries, including the UK and many of our European neighbours, the infection curve is sloping upwards again. In a slew of countries – including the USA, Mexico and Brazil – the infection rate has broadly plateaued. More worryingly, there is a group of countries – including Argentina, Turkey and Ukraine – where the mortality curve has spiked upwards.

The initial policy response worldwide – with some exceptions, such as Sweden – was to impose draconian lockdowns to limit social distancing and thus viral transmission. These lockdowns were broadly successful in that aim though some worked better than others. But it is now clear that nations cannot endure lockdowns indefinitely – in fact, about three months seems to be the cultural and economic limit. Beyond that, the cost of the lockdown exceeds the cost of the pandemic. That is, no doubt, a lesson for the future.

The end of national lockdowns in all but a handful of countries has resulted in an uptick in mortality. And the global 7-day average mortality curve remains stubbornly flat. So, it is not correct to say, as many do, that we are in a second or even a third wave. We are still enduring the first year of a highly persistent viral pandemic – albeit one which is much less fatal than others that the world has endured in the past.

The cure may or may not be a vaccine. (I’ll investigate that soon.) But it’s clear that we will have to live with this for some time to come.

The United Kingdom: bottom of the class

On all metrics, the UK has fared poorly relative to both developing and developed countries. In terms of mortality, even after the figures were revised downwards on 12 August (because the English numbers were recalculated according to the same criteria as the other UK nations) the UK has endured the highest level of fatalities from Covid-19 per capita in Europe bar one.

In absolute terms, the largest number of deaths has occurred in the USA (189,000[i]), Brazil (122,500), India (66,500), Mexico (65,000) and then the UK (41,500). But, when adjusted for population, the UK has the highest death toll with 611 deaths per one million inhabitants as compared with Brazil’s 576, the USA’s 570, Mexico’s 505 and India’s 48.

Arguably, nations should be compared with their close neighbours to reflect the impact of climate and proximity. On this basis the UK’s mortality rate per capita in Europe is lower only than that of Belgium. Of course, differences in how the figures are collated are important. Belgium’s mortality figure is almost certainly inflated because it includes all people who died with Covid-19 rather than people who directly died from Covid-19 (i.e. Covid-19 being the principal or sole cause of death). Similarly, the Spanish mortality figures are highly likely under-reported because the daily tally has been inconsistently recorded.

The country with the highest number of recorded infections is Russia with 1,005,000 as of Wednesday (02 September). Russia has reported only 17,414 deaths from Covid-19. The UK figures are 337,168 cases and 41,504 deaths. That suggests that the running case mortality rate in Russia is just 1.73 percent as against 12.31 percent for the UK. Or, to put it another way, these figures suggest that anyone who contracts Covid-19 in the UK is more than seven times more likely to die from it as someone in Russia.

That seems, for this writer, quite difficult to accept at face value. Either a much more benign form of the virus is circulating in Russia or treatment there is much more efficacious. Both conjectures seem unlikely. Once again, the figures can often be baffling. One possibility is that our testing regime, although much improved, is still not picking up a large number of people who are suffering from Covid already.

We are on more solid ground when we look at excess deaths. This is the number of deaths recorded over a particular time period – usually a month – as compared with the previous five-year average for that time period (2014-19). This will supposedly capture all the deaths directly caused by the Covid-19 pandemic (which obviously did not occur in previous years because this is a new pathogen) plus deaths that were caused indirectly – amongst which, anecdotally, deaths from cancer resulting from interrupted treatments that would not otherwise have happened. UK hospital waiting lists, at about 1.85 million people, are at record levels. But even that, according to Macmillan Cancer Support, implies an alarming backlog of undiagnosed cancer.

Based on excess deaths per 100,000 people, England has had the highest excess death rate in Europe with 7.55 percent above the five-year average in the week ending 29 May. In global terms the UK came out in third place, after Ecuador and Peru – two countries which have endured catastrophic pandemics. While none of the UK nations had a peak mortality rate as high as Spain, excess deaths were geographically widespread throughout the UK, whereas in Spain and Italy they were highly localised. (Lombardy in the case of Italy, especially Bergamo). The London Borough of Brent recorded the highest level of excess deaths in the UK, at 357.5 percent in the week ending 17 April.

One study[ii] suggested that the UK lockdown killed two additional people for every three who died of Covid-19 by the beginning of May. About 16,000 people died from missed medical care by 01 May. 6,000 died because they were too afraid to attend A&E. Another 10,000 died prematurely in care homes. A further 26,000 people could die in the next six months in the UK due to restrictions on healthcare. On the other side of the balance sheet, about 2,500 lives may have been saved during lockdown thanks to less air pollution and fewer road deaths.

If there was ever a clear trade-off between mortality and the economic impact of the pandemic, then the UK fares poorly on that basis too, being one of the worst affected national economies in Europe and indeed the world. The UK economy in Q2 2020 contracted by 20.4 percent – more than any other European country except Spain. (I learn this morning that India fared even worse than the UK, contracting by 23.9 percent[iii].)

I have already attempted to explain in a previous Journal entry how the poor British numbers can be explained. One highly likely reason was the decision at the beginning of the lockdown (late March) to move vulnerable elderly folk out of hospitals and into nursing homes without testing them for Covid-19. That failure was compounded when carers, untrained in disease management, were permitted to operate across several nursing and care homes without adequate protective equipment, thus super-spreading the virus amongst the most vulnerable. Another factor is the UK’s relatively high level of obesity and diabetes which are clearly important risk factors – though the UK scores behind the USA and Mexico in the fat stakes. And let’s not forget that about one in five patients who died from Covid-19 in English hospitals had dementia. Population density and demographics are also significant factors. The UK has an older population than the Netherlands which has a higher population density.

Further, the government’s failure to restrict entry to infected travellers at our borders during the lockdown will surely be seen as further aggravating the spread of the infection. The issue of porosity (which I have discussed before) was considered much too late.

In terms of the severity of the economic impact, the UK lockdown was imposed later than those in most EU countries and lasted for longer. The UK economy is also more highly dependent on consumer spending and services than our peers, and these were disproportionately affected. The UK may be able to achieve some semblance of a V-shaped recovery as the hospitality sector cranks back into action. But the economic impact of the excess deaths experienced has still not been quantified. Further, the long-term negative economic impact of the disruption to children’s education is unquantifiable.

There are clearly many things going on here. But, in terms of the political fallout, I don’t think that the Johnson government will ever be able to shake off the perception that its handling of the pandemic was weak. Significantly, an opinion poll out this week from Opinium shows the Tories and Labour neck-and-neck, both prospectively with 40 percent of the vote. This is the first time that Labour has equalled the Tories in popularity for years. Significantly, 47 percent of respondents thought that the Johnson government had handled the crisis badly.

And the fact that fewer British workers have physically returned to work than in competitor countries suggests that levels of confidence in the UK are lower than elsewhere. 80 percent of Germans are back at their workplace, but only around 60 percent of Brits. London Underground is reporting passenger numbers still at one third of the normal level.

Record numbers of young people are now on benefits. The number of under-25s on Universal Credit rose by 250,000 during the lockdown to 538,000. Many youngsters will not be returning to school this week. The most critical factor going forward is likely to be confidence that the virus is under control. That confidence is still lacking.

Unknowns

Sir David Spiegelhalter, professor of the understanding of risk at Cambridge University, has been one of the media fixtures of the pandemic in the UK. Scientists usually try to explain things; but in late July Professor Spiegelhalter admitted to New Scientist that Britain may never know exactly how many people died from the coronavirus pandemic because there was not enough testing at the outset.

The idea that the virus could already have been extant in Europe well before the reports emerged from Wuhan is also gaining ground. Another cluster of unknowns surrounds the long-term health effects of the coronavirus. It may be that many sufferers are condemned to live out the rest of their lives with chronic conditions. We do know that about one in ten of people who recover continue to experience fatigue, muscle weakness and neurological disorders.

What if a resurgence of Covid-19 coincides with an outbreak of seasonal flu this winter? In late July, the UK government announced that the winter flu vaccination programme would be expanded this year. But if anyone succumbs to classic flu-like symptoms, they will not know if they have seasonal flu or Covid unless they get tested.

On the plus side, clinicians hope that the spread of seasonal flu will be attenuated by social distancing, face coverings and sanitising. Recent data from the Royal College of General Practitioners suggest that cases of communicable respiratory and chest infections such as bronchitis, hepatitis, asthma, tonsillitis and even of the common cold have plummeted since March. Chickenpox is down nearly fivefold and laryngitis threefold. Cases of conjunctivitis have halved. No doubt the closure of schools has cocooned children; and adults have been having less casual sex. That said, any flu outbreak will complicate the management of the coronavirus pandemic.

In Australia, there has been much less seasonal flu this antipodean winter than last year. So, it seems that social distancing works. The Japanese health minister even suggested that Japan’s low infection rate was attributable to mindo– the Japanese code of courtesy that involves bowing, but not handshaking.

In fact, some people think that mindo and other East Asian courtesy rituals arose in times of pandemic. The Quran commands believers to stand a spear’s length away from an infected neighbour – roughly two metres[iv]. Indeed, ablutions (sanitising) are a hallmark of Islam – as they were of medieval Christianity; though the practice of washing oneself before entering Church seems to have been lost in the Reformation[v].

The working hypothesis is still that Covid-19 originated in a bat cave somewhere in Yunnan Province or nearby. It is highly likely that all kinds of zoonotic viruses have leapt the species barrier in recent history – and that most were harmless. This one is pernicious because it is uniquely contagious and causes respiratory failure in vulnerable adults.

But Covid-19 should be evaluated in context. HIV/AIDS has cost about 32 million lives since it first emerged in the early 1980s and is still killing people. That probably started in monkeys and was brought into human circulation by bushmeat hunters in central Africa. Aids was never a gay plague.

For most of us the risk of dying from Covid-19 is statistically tiny; for children it is negligible – only three under-4s have died so far in Britain. On the other hand, for the over-90s the risk of dying from Covid-19, once contracted, is equivalent to doing a sortie with Bomber Command in WWII.

The first outbreak of Hendra Virus occurred in a suburb of Brisbane in 1994 when a racehorse dropped dead having infected humans with an unknown pathogen. It took years to work out where the Hendra virus originated; but eventually it was traced back to our old nemesis, the fruit bat.

What will the next zoonotic virus entail? Nobody knows. And animals catch diseases from us. We’ve probably been exchanging pathogens with animals for the last million years – and shall continue to do so until we escape to Mars.

[i] All figures from https://www.worldometers.info/coronavirus/ accessed 02 September 2020 and rounded to the nearest 500.

[ii] The paper presented to SAGE in mid-July used statistics from the Department of Health, the ONS, the Government Actuary’s Department and the Home Office. See: https://www.telegraph.co.uk/news/2020/08/07/lockdown-killed-two-three-died-coronavirus/{paywall}

[iii] See: https://www.economist.com/asia/2020/09/03/indias-economy-shrinks-by-a-quarter-as-covid-19-gathers-pace

[iv] There is an interesting discussion of pandemics from an Islamic perspective at https://www.alhakam.org/prophet-muhammads-teachings-regarding-pandemics/

[v] See: https://en.wikipedia.org/wiki/Ablution_in_Christianity