Am I enough? Am I doing enough?

There is no duty we so much underrate as the duty of being happy. By being happy we sow anonymous benefits upon the world. - Robert Louis Stevenson
Look all around, and what do I see / Anything I want to, surrounding me / Can’t change the world, or what it believes / But when I look in the mirror, I’ll believe in me / Cos the moment is near, and I can only do the best with what I’ve got - that’s what takes me higher, yeah / no more tears, only sunshine in the rain - that’s what takes me higher / no more fear, just an open doorway in my mind - that’s what takes me higher. - Sarah Caltieri, No More Tears
We live in a house of mirrors / Reflections don’t make it clearer / Do we wait, meditate or fade away? / Everyone's so serious, and on the run / We should be delirious, and having fun / Slow down, look around, you wear the crown / Time flies, in a second / Close your eyes, you’re going to miss it / Oooh I found the secret / All we gotta do, all we gotta do, is / Dance, sing, laugh, love / You want it, you want it / Dance, sing, laugh, love / You got it, you got it / Dance, sing, laugh, love / You want it, you got it / Life should make you feel good / Life should make you feel good. - Jewel, Dance Sing Laugh Love

I’ve been struggling a bit lately with a sense of mediocrity and a feeling of confusion about what I should be trying to do with my life. I can’t seem to shake the belief that I owe someone something for my existence. That I need to make it worth the while. But I don’t know what that even means, and it’s too easy to look at myself and find fault with how I’m doing.

Part of the answer is to see that I am just a phenomenon that this universe has produced, not a true ‘self’ with unlimited agency and free will. To judge myself negatively for being anxious or unfocused or socially challenged is as inappropriate as judging a tree negatively for growing tall. Recognising my limitations, I’m always left with just disappointment that I’m not someone else, someone that would seem better to me. But that’s ego, identifying too strongly with this temporary, emergent self, as if there is some ‘I’ at the root of it that could be held responsible for its quality as measured on some arbitrary scale.

The other part of the answer, I’ve now concluded, is that the best and most meaningful way to live is to constantly look for what good you can do and do it. And I don’t want to limit ‘good’ to some worthy, moralistic sense of doing charitable acts. Years ago on another blog I wrote about how multicolour, paradoxical, surprising and amazing goodness can be when you stop trying to squeeze it into simple and legalistic boxes. It’s worthwhile to remind myself about that. Goodness is anything that brings anyone joy, or that lifts anyone higher. Including you yourself. And you have to feel into that to know. It can take the form of overcoming a challenge; following a passion and pushing the limits of what you can do (watch Until The Wheels Fall Off for a stunning example of that); sharing a vulnerability and making a connection; creating something beautiful. Not everyone can make large-scale contributions to stopping wars, fighting corruption and injustice, developing solutions to complex global problems, etc. But I think we all have ways available to us of turning towards the good. Maybe we just need to stop and look for it every now and then.

For me one of the biggest things keeping life bleak, mediocre, and meaningless is excessive fear. It turns things into black-and-white absolutes (i.e. X would be absolutely bad, and absolutely must not happen), which is not accurate. Sometimes embodying or achieving something good incurs a risk of bad things that can be worth it. Sometimes bad things even bring unexpected good, or can be made to produce goodness. (Absolutism about that has always been much harder for me to swallow, funnily enough. I don’t believe that what doesn’t kill you always makes you stronger… if this was true we should wish non-fatal calamities on everyone we care about. Similarly, always had issues with “suffering is a choice” and circumstances being indifferent with regard to wellbeing. Maybe another post some time.)

I guess I wanted to live a life that was about something more important or impressive than a struggle with anxiety. Of course, my life is more than that. That thought itself is another distortion. But that struggle chose me, even if I didn’t choose it.

Excessive fear is a big road block but it’s a potential gift, in a way, because it’s a huge mass of potential for goodness, for meaning, for joy. There is nothing quite like that heady feeling of freedom when you conquer your fear.

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Masks forever?

There are arguments over the effectiveness of some covid measures. Similarly there is some room for disagreement on how bad the negative side effects of measures are. But the most stark disagreement seems to be over whether covid remains unpleasant or dangerous enough to warrant a “new normal”, where we continue to make transmission suppression efforts that we never made before (such as masking, or avoiding crowds or busy indoor places). Some see these interventions as now belonging in the same category as seat belts, treatment of water to make it safe to drink, sunscreen, and toothbrushing. I found this surprising, and have tried to understand how different people can think so differently about this.

Pandemics have always come and gone; I never envisaged that the old normal wouldn’t come back. Especially if there was an effective vaccine. I guess I believed early on that this virus would become endemic, and that immunity was going to be the way out of the crisis, however painful a process it entailed. My hopes are pinned on our ability to adapt to its presence, to the effect that more frequent exposure may even be better for most people – making covid less unpleasant and dangerous (more often asymptomatic or mild). It certainly seems ordinary colds are hitting people harder now with the immunity debt caused by lockdowns.

If this is true then, in the long run (and post vaccination), on average, harms are paradoxically mitigated by opening up. More covid = better health! But like all hormesis phenomena it isn’t black and white. There is risk involved with exposure to covid. It will happen to virtually everyone sooner or later, but for some individuals, maybe less frequent exposure – i.e. delaying the inevitable, and fewer lifetime infections – is worth the cost of somewhat restricted social lives and indefinite N95 usage.

Even the sunscreen example has an element of that – using high-factor sunscreen makes you stay pale and therefore more vulnerable to burning; it also inhibits vitamin D production. But adaptation to sun exposure does carry the risk of skin cancer. Similarly, adaptation of young children’s immune systems to a milieu of viruses sets them up for good health, but the exposure also brings some risk of severe illness and even death – even with the more major threats removed by immunisations.

But I think a lot of the “masks forever” people do not see the virus as something humans can adapt to at all, and they express anxiety about nasty, as-yet-unknown harms that will emerge over the longer term. This is arguably no different from the people fearing the exact same thing about the vaccines. It seems like for those who are inclined to be afraid, what you fear is dictated by your political tribe, which is interesting as well.

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Covid vaccination for healthy 5-11 year olds

The NHS are treating this as a vaccination campaign, posting out appointments that haven’t been requested. I feel this approach is at odds with the JCVI advice. Let’s look at a few parts of the JCVI statement:

  • What was advised was a “non-urgent offer”, not a campaign.
  • Interesting wording around what the intention is. Tempting to think the anticipated payoff is more to the overall transmission dynamic within the whole population, than to the individual children.
  • This is further suggested by the admission that it would be a “one-off pandemic response programme” without any commitment to put it in the regular childhood immunisation programme (and “endemicity” acknowledges covid will be around indefinitely). It’s about flattening curves, or trying to. I’m not sure this has really been spelled out to parents.

-> Brutally honest, and should all be in the patient information leaflet.

-> Strongly suggesting it won’t be worth it to offer this vaccine once the pandemic phase is over and we no longer fear big waves.

After this statement was made, real-world data showed terrible efficacy against the new Omicron variant for this vaccine (down to 12% against symptomatic infection). I thought they would pull it, since the declared threshold for acceptance of any covid vaccine back in 2020 was 50%. But the campaign is underway anyway, and they have not communicated this new information to parents either.

The vaccine seems to be safe, and I don’t really care what other parents decide for their children. I just wish public health was more transparent and honest. I also think this is probably a massive waste of resource that could be better used on plenty of other things (for example, chicken pox vaccination).

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Pandemic thoughts over the last few months

Pandemic mitigation measures have mental health side effects

I’ve struggled with anxiety much of my life. In therapy I learned not to put my life on hold to avoid risks… and then a pandemic came along and I’ve been forced, along with everyone else, to do just that. I’ve been forced into the kind of safety behaviours I’ve previously worked hard to stop. I get why, of course, but it has been problematic for me.

I recently tested out how it felt to not wear a mask in a supermarket. It made me feel nervous about breathing, as if the air inside the shop is toxic. That’s what I’ve internalised over nearly two years.

It’s not just me. From the beginning we all had to participate in measures to inhibit the spread, and this seems to have conditioned most people to believe that they are protecting themselves from danger, despite the huge risk gradient with old age. It didn’t help that we had to ditch the narrative of flattening the curve with its unpalatable implication of accepting some severe disease and death. The aim was to save lives and protect the NHS, but you were more likely to see shops and restaurants and schools and so on claiming they are “keeping everyone safe” with hand sanitiser and screens and distancing. This continues long after mass vaccination! As well as both expressing and creating excessive anxiety, I think it also fuels conspiracy theories that may seem to make more sense to people who are immune to excessive anxiety and can see what utter bullshit “keeping everyone safe” is.

The slow pace of return to normal frustrates me so much. I desperately want a day to come when I can go into a shop or restaurant and never once have to think about that virus. And if not now, after 3 vaccinations, then when?? What more is going to change?

It’s been very strange to me that people who aren’t generally anxious types express feeling “not ready” for mask mandates to go or mandatory self-isolation to end, or they uncritically echo sentiments about “staying safe”. But I guess for most people it’s not a huge problem becoming used to safetyisms. It’s only for someone recovering from anxiety that there is always that awareness of how it becomes a trap you can’t get out of. I’m not willing to accept that this is how it is now, for ever.

The rationality of bug-chasing – or at least, we need to move on from “avoid it at all costs”

Rachel Zoffness in this video discusses “bug-chasers” (people who sought HIV infection). I got it immediately. The relief of getting something you’re terribly anxious about, out of the way, is sometimes strangely attractive. I felt like that when I got my first AstraZeneca shot. It wasn’t that I’d seen enough data yet to convince me the VITT risk was tolerably low in my age-sex group. It was more that I was tying myself in awful knots over the issue and I just needed it to be over.

The messages of “you don’t want omicron, don’t seek it out” have massively stressed me out, against the backdrop of the growing consensus that it’s going to be endemic and we’re all going to get it multiple times (which some have been saying for a long time). It’s kind of like telling a pregnant woman, you don’t want to give birth because it might not go smoothly. Try to avoid it.

Let’s just be clear, if you believe (1) it’s inevitable you’ll be exposed at some point before too long (which is the implication of “endemic”), and (2) the danger (or even just unpleasantness) in that first exposure will only increase the longer it takes for it to happen after being vaccinated/boosted… then you will rationally conclude it’s better to have the exposure now. It’s never going to be any safer.

I read recently that if you’re exposed to a virus and don’t get infected because you have antibodies, your immunity still gets a boost from that exposure. That would be why little kids have constant runny noses in the first year of nursery, and then barely get a sniffle. I’ve heard often it’s the same for staff working in nurseries – they get ill a lot at the start, then are hardly ever ill after that despite swimming in a constant soup of germs. Their immunity is continually boosted without the need for symptomatic infections.

We were ill constantly for months when Eilidh first started nursery. I expected this autumn to be the same, as everyone was saying lockdowns had weakened herd immunity. But it wasn’t. I started to realise we have come through the other side and yet I hadn’t moved on from crisis mode where I can’t plan anything because we might be ill and I count down the weeks to the next nursery holiday hoping we can get through them relatively unscathed.

Which is basically what the public health leadership have been doing in this omicron wave.

The only way out is through. We need leadership that recognises that and instils courage, and advises on how to prepare for the journey. Instead all we get is fear-stoking, safetyism, and confusing shit. All of which is either bad for your mental health, or else it fuels suspicion about the vaccines.

I don’t feel safe

Not so much because of the virus, now, but because of the shocking realisation over the last year and a half that nobody in charge of anything knows what the fuck they are doing. It’s coming out as anger.

  • There has never been strong evidence for cloth masks and nobody seems to have tried to generate any quality evidence over this pandemic. Same could be said for several other measures.
  • Two metre distancing in long meetings, perspex screens – has no-one heard that aerosol transmission is a thing?
  • Sanitiser, deep cleaning, disinfection of “touchpoints”, advice not to share pens(!) – have they not heard that surface transmission isn’t much of a thing?
  • Setting dates far in advance for dropping of mandates – who decides that, and how?! Likewise coming up with stepwise and pseuo-quantitative frameworks for lifting measures, as if there could possibly be any evidence to lift measures that have no evidence in the first place.
  • What is the sense in mandating vaccines for an endemic virus, that can’t stop transmission or eradicate the virus (unless you boost everyone every 3 months), and therefore beyond the first few months only really benefit the recipient. All the vaccines do is ensure some of your first few exposures are “safe”, because they’re to the vaccine and not the virus (although it must also be acknowledged there are some severe and even fatal vaccine side-effects…) so that when you later meet the virus you’ll have a head start. It won’t be long until there’ll be no difference between being vaccinated or unvaccinated: those who didn’t get the vaccine will get their first exposures to the virus instead and ultimately be in the same place. If you want to mandate vaccines, mandate them for over-65s – at least that would have a noticeable impact on hospital admissions and deaths. Not for all these other groups that are being coerced (around the world)
  • Inaccurate memes posted on social media by NHS organisations, minimising dangers of vaccination and making false comparisons. Doesn’t it make you go slightly crazy to realise they can’t be trusted to provide balanced and accurate information?

What will endemicity look like?

Covid is not, yet, like anything we’ve lived with before. It feels like it could easily ruin a holiday even if you were allowed to travel with it, because it’s nasty and very catchy and it’s still surging unpredictably all over the place. No-one ever used to hesitate to book a holiday because they might get ill while on it. Will we ever get back to that? If we were to just treat it like any other illness and go back to normal, how often would we all get it? How often would we have 1 in 20 people infected at once?

I suppose the dynamic of an endemic virus depends on how transmissible it is, measures taken to inhibit spread, how long immunity lasts, and then if immunity can be topped up asymptomatically through exposure (I think this is probably the case).

They talk about the very high R0 of covid now, that it’s nearly as infectious as measles. I get the impression that’s unusual, i.e. other colds are not like that. So what effect will that have in the endemic state?

For a start, I don’t really understand “endemic state” at all. Given the huge number of viruses causing cold symptoms, we must get infected with each individual one very infrequently. Yet it doesn’t seem to take long for young children to build up a good level of immunity to common viruses and stop getting ill constantly – maybe a year. Can they have had all the hundreds of viruses in a year? Surely not.

Adults notice an increase in our rate of infection when our child starts nursery or we start working with young children. Presumably because life before that – including going on buses, working in an office, going in shops, restaurants etc – did not provide the same level of exposure. But our immunity adjusts, similar to that of a young child. It seems like whatever our regular level of exposure to viruses, we eventually somehow settle into a state where we get ill maybe 2-4 times a year!

The difference with covid might be, if it’s really so much more transmissible, then close contact isn’t needed for exposure. Maybe we will all have regular exposure just from walking past people in shops or sitting next to them on buses. What difference will that make to the dynamic? Maybe not much in the end. Maybe we will just settle into the same sort of equilibrium we all have with the other viruses whatever our exposure level to them… however that works.

If anyone knowledgeable happens to read this, please do let me know.

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How much did Covid-19 change our risk of death?

When I looked at excess deaths before, I didn’t think to actually notice what the normal rates of death in each age group look like, and how comparable or otherwise the age distribution of covid deaths (or excess deaths) was to the usual distribution of deaths.

Here’s the 2010-2019 average mortality rates by age group in Scotland, with the excess deaths from the first year of the pandemic stacked on top:

And here’s the proportional change in the death rate over that first pandemic year in each age group.

Excess deaths in the first year of the pandemic as a proportion of expected annual deaths

Now here is a second version, where for under 45s I’ve used “covid confirmed” deaths (from the PHS covid dashboard) instead of excess deaths, as they are rather different in those age groups:

Ditto, but with excess deaths replaced by covid deaths for under 45s.

Some things that stand out:

  • Above age 65, your proportional increase in probability of death over that year seems to have been bigger the older you were. I imagine exposure may be a factor in that – the likelihood of receiving social care and/or hospital care increases steeply with age, and these would obviously be sources of potential exposure.
  • The biggest proportional increase (in the second version, i.e. focusing on covid deaths) was in ages 45-64. Presumably because 65 is a typical retirement age, and many people under that age will have been working outside their homes, and thus more exposed.
  • Below age 45, exposure risk must have been at least as high as for the 45-64 year olds. But proportional increase in deaths due to covid was much lower in younger people.
  • On the other hand, the 15-44 age group really did not fare well overall, with the highest proportional increase in total deaths of all age groups. As I noted in my previous post, many of the excess deaths specifically in this age group occurred over summer 2020, so cannot have been covid deaths as we had barely any covid cases. Maybe a collateral harm of lockdowns? Have to wait for NRS vital events publication for 2020 to see causes of death by age.
  • On the other-other hand, lockdowns appear to have reduced deaths from non-covid causes in children under 14.

Mostly I just feel surprised to see how high the background risk of death is, at every stage of life. Forget pandemic viruses, and risky vaccines – just plain living is way more dangerous!

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Should a forty-something woman in Scotland take the AstraZeneca vaccine?

A study published in the BMJ found that, among 18-65 year olds in Denmark and Norway who’d had the AstraZeneca vaccine (mostly healthcare workers), the rate of “excess” thromboembolic events (blood clots), i.e. ones that wouldn’t have been expected to happen anyway, was 11 per 100,000 people. This is an order of magnitude higher than the official rate that Public Health England is giving, probably because the population who have had the vaccine in the UK have generally been older, so there have been fewer cases (so far). The rate seems to be higher in women and in younger ages. The concern is that it’s causing an unusual type of clotting condition (VITT) that is much more likely to be fatal than a typical leg clot.

For a woman in her early forties, then, who is currently at the top of the queue for vaccination but is being prevented from accessing any other vaccine than AZ by her country’s vaccination policy, is it worth the risk? It’s difficult to assess. I don’t know when or if I might be able to get a (seemingly safer) mRNA vaccine. And I don’t know what my risk of exposure to coronavirus in the meantime will be.

One thing I have tried to quantify by way of comparison is the risks that I have lived with over the pandemic so far. I’ve updated my excess deaths analysis and looked at the 15-44 age group (I can’t break it down further). There were 280 excess deaths (0.13 months’ worth) over the whole of 2020 and first 16 weeks of 2021, and strangely, a lot of them seemed to occur over last summer when there were no covid-related deaths being recorded. So maybe just a random fluctuation. There were 13.6 excess deaths per 100,000 population in that age group in Scotland over the pandemic so far. The “covid confirmed” deaths in females aged 25-44 works out at about 3.5 per 100,000 population, so that’s probably a better sense of the risk.

On the specific issue of blood clots, a very recent study has looked at rates of occurrence of blood clots in covid cases. I took their numbers and applied to Scotland’s total covid case count (roughly inflated to account for lack of testing in the first wave*). I make it that about 134 cases of blood clots (CVT or PVT) would have occurred in Scotland to date in people with covid, which is 0.0025% of the population. (I don’t know if age is a risk factor.) This represents all instances in people with covid, not the excess risk. Even so it is not as high as the 0.011% excess risk of a blood clot in 18-65s from the AZ vaccine. However there could be other types of blood clot caused by covid besides CVT and PVT that are not included in the 0.0025% but are included in the 0.011%. I don’t know.

Finally, I used data from the ONS long covid survey to look at the risk of having symptoms that limit your activity a lot and that have gone on for more than 12 weeks. That’s a scary covid outcome. In the 35-49 age range, about 0.25% of that population seemed to be affected as at 6 March 2021. That number will not include cases from the January surge as that would have been less than 12 weeks prior to the survey. It also wouldn’t include anyone who had it earlier and recovered before the survey. But it will certainly capture a lot of cases from the autumn wave.

I do worry about long covid. It’s not rare at all. About 5% of people who’d ever been ill with covid up to mid-December (again, inflating the first wave case count to compensate for lack of testing) were still ill on 6 March to an extent that limited their activities a lot. However, the median duration of symptoms is stated in the report to be 35.5 days – and that presumably won’t take into account asymptomatic infections (the Scottish Government have an ad campaign to encourage compliance with restrictions and one of the ads states “1 in 3 people don’t know they have it”. That would amount to about 140,000 undetected infections in Scotland so far).

It’s a subjective, emotional decision as all decisions are. At the moment I don’t feel convinced to take AstraZeneca. It seems reasonable to hold out for the chance of an mRNA vaccine. There is nobody especially vulnerable around me that hasn’t been vaccinated themselves. The mRNA vaccines are a better choice, and normally healthcare practice is to provide choice, so it feels inappropriately coercive to be encouraged to take AZ and offered nothing else, and to be threatened with “going to the back of the queue” for refusing. That tends to make me dig my heels in. It also doesn’t make me feel assured that they would take symptoms seriously and do everything necessary to save my life if I developed VITT.

If there really aren’t enough mRNA vaccines for everyone left who wants one, then they can order more. Those of us who aren’t in the priority groups can afford to wait. Ideally, I’d like to see people at higher risk around the world given vaccines long before the West starts vaccinating its children – which it is already doing. Excessive covid-safetyism has bothered me all through this pandemic and now it’s manifesting in both nationalist vaccine greed and pushing ahead with a vaccine that is statistically going to kill some people (while other safer vaccines exist).

Deaths of forty-something women are starting to hit the news, just like clockwork. BBC presenter Lisa Shaw, 44. It could be a grim few weeks.

*by assuming that death counts are complete throughout and case fatality ratio did not change

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Herd immunity was in everyone’s plan at first

Something else that seems very significant looking back. The whole paradigm we had in the beginning, of having a “contain” phase that is fairly quickly abandoned and moving on to a “delay” phase. This apparently was developed in planning for a flu pandemic:

Scientists are used to seeing flu spread through populations very fast, then become milder as it mutates, and to seeing people indeed develop immunity and populations become resistant.

[The flu strategy’s] first “detection and assessment” phase (seemingly an analogue for the “contain” phase of the coronavirus response) describes how the focus would shift away from “actively finding” and isolating confirmed and suspected cases, and instead turn to treatment of the disease once there was “evidence of sustained community transmission of the virus”. It even anticipates that detection and assessment could itself be a “relatively short” phase, depending on the circumstances. The flu strategy bluntly concludes: “It will not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so.”

It wasn’t just the UK that used this concept – it was everywhere. That cute animation gif showing the curve flattening – that was from New Zealand! (Full article) And wrapped up in that curve-flattening, peak-delaying concept is all the stuff that became abhorrent and governments had to distance themselves from – herd immunity, letting the infection spread in a managed way, accepting that people will die. It was all there in the world’s pandemic flu preparations. (Maybe a pandemic flu instead would have been a bit slower to spread and a bit less deadly. Would that have meant societies did not reject this paradigm? It’s hard to imagine.)

Clearly, New Zealand moved on from that model pretty quickly. Our government was one of the slowest to let it go. But we all moved on to suppression (and I think East Asian countries basically started there, having had the experience of SARS 1). Even Sweden doesn’t talk much about herd immunity.

I guess those countries that moved on to suppression fastest, were able to have the option of actually eliminating the virus and then closing borders / setting up managed quarantine to keep it out. In one of my earlier posts, I sort of dismissed this idea as “having its own problems”. I’m sure New Zealand tourism and economy as a whole has taken a massive hit, but as a price to pay for keeping the population safe AND getting to live relatively normally, I’m sure most would agree that it now looks like the best of a bad bunch of choices.

Wouldn’t it be great if we had all started from a point of view where we believed it could be stopped and eliminated? Maybe it could have been! I guess we can only hope that these lessons will save us all this pain the next time.

Because of course once it’s spread so far, we start to face these awful dilemmas between the harms of letting it spread and the collateral harms of the humongous heavyweight and continuous measures it now takes to suppress it. A lot of my frustration with our governments in 2020 has been the lack of transparency – and lack of public debate – on where we position ourselves in this balancing act. Sweden at least was clear that its measures were designed to be evidence-based to avert disaster and be sustainable for a long time. Here, we seem to have flip-flopped all over the place. In the summer the Scottish government was talking about pursuing elimination – yet they aren’t able to close Scotland off, and they have allowed cases to rise an awful long way in the autumn before putting in heavy restrictions… so I guess they don’t really know what they are trying to do.

Then again, why should I expect them to? In the early months it felt impossible to stomach either option: letting it spread, or the prospect of indefinite continuous suppression. At least now, there seems to be light at the end of the tunnel with these vaccines being rolled out.

And the vaccines will help us get back to normal, but not everyone will be able to get them, not everyone will want to get them, and they will not work for everyone – and even when they work, the immunity perhaps won’t last forever. Endemic equilibrium seems the inevitable (and relatively benign) end-point but how much more pain before we get there?

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Covid pandemic, 9 months in

I’ve been looking back over my posts through this pandemic year, trying to make some sort of sense of where I stand after everything I’ve learned. Not that it really makes any difference what I think… but I like to see how much my understanding has changed over time, and how consistent or otherwise my views have been.

Public opinion seems to range from “only zero covid is acceptable” to “this is all a big fuss about nothing”, and neither of these extremes are a tiny wacky minority. SARS-CoV-2 is so sweepingly diverse in its actions in humans that it has supported massive polarisation of views on its management, which is perhaps one of its more sinister (and less talked-about) outcomes – the furthering of fractures in society. As I’ve mentioned before, at times I’ve felt unstable and confused in my own thinking, pulled in different directions – which is why I’m craving clarity, I guess – but perhaps it’s better in some ways to remain open and uncertain.

The lockdown approach has seemed overly destructive to me: Sweden showed in the summer that case numbers could come right down without shutting everything down, possibly through a bit of natural saturation, summer season, and social distancing. It made me think probably our own lockdown (and that of many other countries) had come too late to do much good. It also lasted way too long. We gradually moved towards Swedish levels of openness-with-precautions, which was working fine in Sweden, but we didn’t quite get there before the season changed and cases started going back up. Soft play has been one casualty of that that is close to my heart.

The situation was OK in the summer. I felt there was too much pessimism and fear. Maybe I was wrong about that. Contact tracing clearly hasn’t worked well enough to prevent another big wave (is anyone surprised? – well, it looked hopeful to begin with). But I didn’t think a new wave in the autumn would be as bad as the first, and I guess it wasn’t:

I had definitely hoped things wouldn’t get as bad as they did. We have probably gone into excess deaths* again – but lockdowns also cause deaths, poor mental health, wrecked livelihoods and future prospects, and other harms. Things were at least coming under control without resorting to lockdown. It seemed hospitals were coping. So I still felt we should hold our nerve and keep going with what measures we had in place.

I think there is too much emphasis on counting covid deaths without viewing them in the context of overall mortality. Sometimes it feels as if no-one ever died before. I also want to ask for each intervention: who benefits, and who pays the price for it? And are we comfortable with that?

I didn’t think restrictions should be relaxed at Christmas. Learning about the pandemic’s overdispersion has changed my thinking a lot: “9 percent of cases were responsible for 80 percent of transmission, while 69 percent of cases did not infect another person”. Where people gather indoors, in close contact for prolonged periods with little ventilation, a lot of spread happens. You’re not likely to catch it walking past someone in a shop (if not crowded) or even from surfaces. Why should shops have to shut and meanwhile people are allowed to visit each other at home over the holidays?

Yes it’s hard to forgo our usual social contact, but in most cases doing so is not as harmful as the overall results of people breaking the rules and gathering: full hospitals, deaths, more lockdowns. I feel I’m turning into one of those judgemental types that blames the spread on people’s behaviour. (Not entirely – secondary schools, universities and certain workplaces/work situations are also implicated, and there’s not much individuals can do about any of those.)

Anyway, and now we have this new, ~56% more transmissible strain that throws everything up in the air. A three-week anticipatory lockdown after Christmas has been implemented. Cases seem to be going up again sharply, and I don’t think it can all be explained by the new strain (although the new strain is making up ~40% of cases).

So I don’t know what I think any more. Maybe if it transmits faster now, it will reach a saturation point faster. The autumn wave seemed to reach saturation, so maybe the new saturation threshold (with this new strain) isn’t much higher anyway. Can only hope that between that and the rapid rollout of the vaccines, we’ll hobble through the rest of the winter and soon be OK.

*ETA: I came across this shiny app for excess deaths. They actually don’t look as bad as looking purely at deaths with a recent covid diagnosis. I guess a fair number of the people in the latter category would have likely died over this winter anyway.

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Thoughts on the Great Barrington Declaration

Three epidemiologists have proposed a different approach to managing the covid pandemic, in the form of the Great Barrington Declaration:

“The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection.”

I’ve been happy to see the conversation broadening out a bit in this way, as I’ve long been a lockdown sceptic and feel that the level of fear in our narratives around this virus has reached unhealthy heights.

I haven’t signed it, though. Part of me wants to – there are definitely things I like in it (and in Sunetra Gupta’s commentary) that I’m just not getting from elsewhere:

  • Recognition of the profound harm of lockdowns. A holistic public health perspective rather than one focused solely on the threat of covid. In the case of Sunetra Gupta, a voice in defence of the world’s poor: warnings that lockdowns will lead to starvation, reminders that being able to stay at home away from other people and be OK is a huge privilege that the majority do not have. And even for those that can, there are still harms.
  • The understanding that the end-point of this pandemic is an endemic equilibrium. Nothing else really makes sense to me. This coronavirus is going to be circulating forever – or at least, we can’t realistically think we can ever eradicate it.
  • Hence, an explanation – a ray of hope – for how the virus will become less of a threat. It’s causing a lot of severe disease because it’s novel. In an endemic equilibrium, we won’t see these big overwhelming outbreaks, because at any given time, many people will have immunity. Reinfections are also expected to be generally milder as the immune system still retains some memory of how to deal with it.
  • Interesting to reflect that if this is true, it will never be a significant threat to today’s children or future generations because they will be first exposed during childhood, at which stage of life it’s generally a mild disease. Maybe the other four circulating coronaviruses would also be life-threatening to the elderly if they had never previously been exposed to them. For that matter, probably those viruses are responsible for deaths (I’m sure Prof Gupta has referred to that), and we just don’t hear about it because there aren’t big waves of serious infections (we have an endemic equilibrium)… and the cause of death is probably recorded as “pneumonia”, i.e. it’s the secondary complications that we consider significant, and the primary infection is almost irrelevant (and not even known). With covid we’ve somehow equated the secondary complications with the infection itself, despite the huge number of asymptomatic and mild infections. Fear fear fear. So, this is something I like and find helpful: framing the coronavirus beside its non-threatening cousins where it can best be understood, and so tempering the hysteria around its novelty.

I think the most obvious criticism of the idea is probably the logistical difficulty of shielding “the vulnerable” while letting the rest live normally. Maybe it would be feasible if we had rapid testing, so that care home workers could be tested at the start of each shift, and visitors tested in the same way. As it is, the physical separation of vulnerable people from their loved ones is extremely tough. And where they live in the same household, it’s hard to imagine ways it could be done. Sunetra Gupta has said she expects it would only take about 3 months for game-changing levels of immunity to be reached under the GBD proposals, so that the difficulties of shielding wouldn’t need to be endured for long – but I don’t think anyone can really know that.

And then there’s the question of how much protection would actually result from reaching endemic equilibrium. There’s been a lot of unhelpful shouty noise about herd immunity being impossible because individual immunity wanes. Herd immunity is not an all-or-nothing thing. Even with lifelong immunity and widespread vaccination, as with measles, the probability of a vulnerable person being exposed is not zero. With a coronavirus in an endemic equilibrium, where individual reinfection might occur every few years, the probability of a vulnerable person being exposed is clearly higher than in the measles case. But still, the GBD people are not wrong to say that a level of herd immunity is built up. The question is, is it enough? And how much would we consider “enough”? What do their models suggest the eventual probability of exposure will be, and what is it now? These are the kind of things that should be asked.

The other thing that bothers me is that we still need to recognise this virus can be dangerous to anyone at high viral loads. Young and healthy doctors and nurses have died of it for this reason. There are certain aspects of normal life – nightlife especially – that I don’t see being safely resumed until most of the population is vaccinated.

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Scotland’s covid whack-a-mole

Tayside’s mini second wave was squashed with testing and tracing:

Grampian’s was squashed with a local lockdown:

Glasgow’s is ongoing, and is being tackled with restrictions on gatherings in homes (as well as testing and tracing, of course). Before I added the last data point, it looked pretty bad. I’m not sure if transmission is genuinely tailing off now or the data is affected by recent delays in processing tests. We’ll have to see.

My general impression has been that things are getting out of control, but looking at these data today, it doesn’t look that way. There are success stories here that no-one seems to be reporting. And most other parts of Scotland are doing OK.

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