Scotland’s second waves

Tayside’s 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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Be more afraid?

I recently read a very disturbing Guardian piece detailing the goings-on in an Austrian ski resort back in March, through interviews with people who had been there. It seems this resort (Ischgl) was a hotbed of transmission at that time and may have played a significant role in the coronavirus’s spread across Europe. Reading it felt like watching a disaster movie. It’s particularly horrifying from a post-lockdown perspective, now that we have (somewhat) normalised the new high standards of hygiene, social distancing, and isolation of ill people, to hear stories like this from the start of the pandemic where none of those precautions were in place. I felt a visceral disgust reading it, and could recognise the “puritanical instinct” the article mentions is being heightened in all of us; the nightlife scenes depicted there would never have been appealing to me before, but now they even feel wrong.

Sometimes I feel like we are all being groomed to be more and more afraid. At the start, fear was something they wanted to avoid spreading. We were told the vast majority of people would only get a mild illness with this virus (when was the last time you heard that message?); that we should wash our hands well, avoid touching our faces, and carry on. There would be an epidemic, but that was OK as long as we flattened the curve so hospitals could cope. Then there was the sudden lockdown, and we never heard that hospitals coped, as it became all about the grim death toll competition with our neighbouring countries. And then deaths went back to normal, or even a little lower than normal; but now we’re obsessed even with case numbers. Zero covid is now the only appropriate ambition.

Is it that we underestimated it earlier in the crisis (and didn’t realise it warranted this much fear)? In what way?

As cases rise, now, blaming fingers are pointed at young people hammered by mixed messages and trying to get on with life. Even permitted social contact is inevitably clouded by guilt and fear, as public health bodies tactlessly warn us not to “kill our grannies” (as Carl Hanegan points out, people kill their grannies with viruses every Christmas, but we never give that any thought). For their own benefit and protection, we strip care home residents of the will to live by removing the social contact and activities that make life worth living.

What psychological toll is wrought on us by being asked to constantly behave as if we are infected with something that will kill someone if we don’t stay vigilant and keep it to ourselves? On the face of it, distancing and mask-wearing and hand hygiene are simple things, and I am certainly not against them. But for some, at least, they are a constant stressor, slowly, insidiously, etching fear deeper into our hearts. I don’t see anyone talking about this.

The worst of the burden of fear is borne by those who had been told to shield themselves from the virus due to their preexisting health issues. These people were directed to keep themselves at home behind closed doors for 4 months in fear for their lives, with no organised support to psychologically manage that situation and maintain rational thinking about their risks. Then at the end of July they were callously tossed out to work again, just as we started to talk about a second wave, apply localised lockdowns to squash outbreaks, and while the narrative around the virus shifts to an ever more fearful one.

It feels a bit ironic that I spent months in therapy learning to live with the constant likelihood of illness, the way everyone else apparently does without any problem… and then a new virus comes along and suddenly the rest of the world flips out and decides illness and death are impossible to coexist with. Which was exactly my starting point.

I honestly don’t know what I think or feel about this coronavirus a lot of the time, or how scared I should be. I feel schizophrenic. I can see it so many different ways. I think we have to try to be rational and balance the harms incurred with different actions, and we are not being helped to do that. We should be. This would pave the way for collective kindness. Some of the things that are shooting up out of this fear- and suppression-based approach – rejection of science and reason, conspiracy theories, covid denial – are truly scary.

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Pandemic deaths analysis

I did some analysis of deaths over this pandemic (because I’m morbid like that).

I calculated expected “normal” deaths for every week of 2020, based on 10-year-average age-specific death rates for each specific week of the year applied to the most recent age-specific populations. I also calculated an upper and lower significance threshold as twice the standard deviation. The graphs below compare these with the actual deaths from all causes (so far), in different age groups.

During the first wave of the coronavirus pandemic, excess deaths (defined by me in relation to expected deaths as calculated above) reached 0.98 of a month’s worth of extra deaths in England and Wales. The tally has since come down to 0.86 of a month for 2020 so far, as deaths have been a little lower than expected after the peak. In Scotland, the excess reached 0.57 of a month, and has since come down to 0.47 of a month’s worth.

The recent lower-than-expected death rates seem to indicate that the deaths of some very old or unwell people were brought forward just a little by COVID-19. Certainly it’s in the older populations that the recent death rates are low enough to reach significance.

Conversely, deaths in the 0-44 age range barely reached significant elevation during the peak. In Scotland, the death rate in that age group has not really come down since April and is still skirting significance. This can’t be due to the coronavirus directly but may be due to effects of the lockdown including reduced access to health services. NRS report that a good chunk of the excess deaths over this year were due to causes other than COVID-19, including dementia, genitourinary diseases and diabetes.

England and Wales analysis:

Scotland analysis:

If anyone reading this can help me with data for other countries, I’d love to expand the above analysis.

(Apologies, the y-axis label in each graph should just read “Deaths”, not “Deaths or cases”.)

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How bad will the next wave be?

The prevailing view has seemed to be that the virus has only reached a small fraction of the population, and that lockdown stopped it in its tracks; lifting lockdown will sooner or later result in resurgence that is just as bad as before or worse, unless we can manage to keep it down with distancing and sanitising and testing and tracing.

But there are other views, and there are certainly observations that contradict the above idea: why did Sweden’s infection rate peak and go down without a lockdown? Why has exponential growth tailed off in such a similar way across countries with a diversity of intervention levels and timings?

One suggestion has been that the virus has spread a lot further through the population than it seems; seroprevalence studies aren’t the whole story as there can be T-cell immunity and perhaps other types of immunity post-infection that we’re not detecting. It would mean a very high proportion of cases were asymptomatic. This seems legit up to a point – but I think extensive, unobserved, largely asymptomatic spread would mean that symptomatic cases would pop up all over the place seemingly unconnected to any others, and I don’t think that’s been the pattern.

Another idea is that a large proportion of the population are inherently not susceptible to the virus and won’t be infected. That doesn’t make sense to me either, because it would be much harder in that case to set off the rapid global spread that happened earlier this year.

I think it’s simply that the idea of exponential growth is wrong, as it’s based on a model in which people move around randomly interacting with others like gas molecules bumping into each other. We don’t do that, we have fixed homes and workplaces and social circles. Without hard borders anywhere, the virus will of course keep spreading, but more slowly. When it enters new susceptible communities, spread will take off exponentially again within those areas, and we’re seeing that in localised outbreaks now.

I don’t think a new wave will be as bad as the first, on a national level. I think the spread, as well as being slowed down naturally as before by limited movement of people, will be further slowed down by distancing, sanitising, masks, and some immunity from the first wave.

Reapplying lockdowns is like cracking a nut with a sledgehammer and I fear more for the collateral damage of that. We seem at times to be fixated on achieving “elimination” at a moment in time, which will be meaningless in the grand scheme of things.

The way we’re operating now – Phase 3 of easing – is pretty much what Sweden has been doing throughout. (Maybe a bit more cautious – I don’t think they’re using masks in Sweden.) It feels to me like a balanced approach that will not overwhelm healthcare. We’ve had a good summer with this approach. I hope we can hold our nerve and continue.

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Blogging daily life

So, I’ve got a new blog site for my daily life updates: https://masksandrainbows.wordpress.com/

That’s where I’ll post them from now on. Visitors welcome, as ever, so feel free to go and subscribe there! I just wanted to keep Meaning and Truth for what it used to be – essays and reflections that I put considerable care into; my deep and thoughtful place.

Writing (almost) daily with a quick rundown of each day during the pandemic has been a very different exercise, but I’m enjoying it, even after nearly 5 months. I always used to do a lot of writing during times of change – I remember writing screeds during my first week in Malawi – I think it helps me process things, or avoid feeling overwhelmed. Also, it preserves memories really well and provides a way of sharing those memories or experiences. Maybe one day Eilidh will like to read about the pandemic she lived through, or the third birthday party she had to have online.

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Is lockdown worthwhile?

It’s so strange to find myself philosophically estranged from most of my social circle in the sense that everyone seems to be heavily pro-lockdown while I’m more of a sceptic. Disturbingly, the non-pro-lockdown voices being heard are mostly libertarian / hard right / anti-vaxxers, and they’re having mass gatherings in protest; I don’t exactly want to be associated with that.

For me the scepticism is: we don’t know if there will be a vaccine. Even if there is, how long will it be until it’s not only ready but available in huge quantities to be administered to the majority of the population?

I find it hard to imagine those countries currently considered “successful” can seriously contain the virus until then with testing and tracing, unless they close their borders or impose quarantine, which has its own problems; I think it will take lockdown-type restrictions on and off to keep the infection rate as low as people want it to be, and I think the human cost of that (e.g. this among many other things) is probably going to be too high – especially if there is ultimately no effective vaccine, in which case it’s just delaying the inevitable.

As for countries (like the UK) that didn’t manage to contain it, I have a hunch that opening up now won’t be as painful as we fear: I think that the infection may have spread a lot further already than official reporting, and / or that the epidemic growth is more self-limiting than Imperial models suggested, so that some places might already have achieved a decent amount of immunity (e.g. London). But what do I know? Nothing really. This is just what makes most sense to me so far.

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Rules and fear

It’s been interesting to see how fully and swiftly a lot of people adopt imposed rules as an entire way of being in this pandemic crisis. I’ve just joined a Facebook group for people shielding (i.e. very high-risk people who are trying to take every possible measure to avoid contracting the coronavirus), and even there, so much discussion is around whether we are “allowed” to do this or that. To my mind, the questions should be, what is the level of risk to me if I do this or that? Some people, simply because they haven’t been told otherwise, are still holding on to a forlorn hope that they will somehow be able to stop shielding after the original 12 weeks is up.

I keep thinking about Sweden, where apparently the citizens are trusted to make their own responsible choices to a large extent, based on transparent information. What has happened in our culture that we have become so dependent on being told what to do?

It sort of reminds me of religious discussions from the blogging days of old. The irony of followers of Jesus reconstructing, from his recorded words, a legalistic religiosity of the very type he tried to dismantle. The realisation that I was never going to fit in to a religious community because I couldn’t fully swallow the rules (although I gave it a good try).

I have some difficulty swallowing the current rules, too. Why can’t I have a picnic or sunbathe in a park, if I can do this without getting anywhere near anyone and evidence indicates transmission risk outdoors is very low anyway? The Scottish Government has already recognised that allowing unlimited outdoor exercise – as opposed to just one spell a day – should make “very little difference” to the infection rate. It seems to me the benefits of outdoor freedoms are huge and the risks are relatively tiny.

As restrictions start to be eased, rules become more and more complicated and harder to make sense of, as this Facebook post (I’ll put a screenshot at the bottom of the post) illustrates well. I’m not saying the UK Government couldn’t have been clearer on Sunday, but it seems obvious we’ll experience more confusion the more we move away from “stay at home” but still expect clear rules for everything.

The current mood in my social media circles is very much one of fear: give us rules, keep up restrictions, clamp down, get this situation fully under control. But what control? As I wrote previously, I’m scared of the fucking virus, but I’m also really scared we will lose too much – outdoor freedoms being the very least of it – by trying too hard to suppress what might be insuppressible. What exactly are we hoping for? As someone wrote in a public post yesterday, “we were never going to social distance this thing into nonexistence”…

I get a great sense of calm from listening to Anders Tegnell and Johan Giesecke. I hear them say the Swedish curve has flattened, even with more moderate social distancing, and this is partly due to the development of some immunity in a significant chunk of the population. I feel that’s good news, if true. And I do feel it makes some sense. Sweden’s deaths per capita aren’t the worst – and Giesecke’s constant refrain anyway is to wait a year before comparing countries (his belief is there will not be much difference by then). Care homes have been a problem everywhere and lockdown hasn’t really helped them.

I also like the UnHerd YouTube channel for its in-depth discussions and interesting variety of interviewees with different expertise. A German virologist gave the most reassuring story I’ve heard about how the virus might become something we can live with, even in the absence of a vaccine (there has been no successful vaccine developed against any other coronavirus) and without necessarily lifelong immunity following infection. He also finds evidence the virus has spread further than official estimates, and the fatality rate is correspondingly smaller.

I suppose I find all this comforting because if they are right, maybe this crisis will all be over sooner than we think. The UK’s horror story of 40,000+ deaths by now – according to these hypotheses – at least reflects enough infections in the population to have produced a decent amount of immunity. So while nothing can take away the tragedy that has happened, maybe the process of opening up will be easier than everyone fears. I certainly prefer that idea to the prevailing conception that our only way to meaningfully un-pause society without risking a horrific flare-up is a vaccine that may or may not be possible to develop.

I guess we all have to find some comfort somewhere, some hope.

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Peak

Supposedly we’re at the peak of the Covid-19 outbreak now, or just past it.

The concept of “the peak” entered discourse in mid-March, in talk of measures to “delay” it with social and behavioural interventions. At the time, we were essentially told that containment had failed, contact tracing and testing was being abandoned or scaled back, and this virus was going to come in an inevitable wave that would peak and then subside – presumably due to enough people having had it and gaining immunity – and all that could be done was to “flatten” that wave to make it more manageable. The peak would then not occur until after the winter flu season had passed, and it would not be so high as to overwhelm healthcare.

When Imperial College modelling suddenly indicated (in an unreviewed paper) that we weren’t doing anywhere near enough social distancing to avert disaster, it seems the government panicked and moved swiftly to a “lockdown”. And we sat in grim waiting to see whether it was enough, or too little too late.

But between then and now, almost imperceptibly, the goal posts shifted. “Delay” dropped out of the discourse, giving way to “suppress”. There has been very little reporting on how well or otherwise our healthcare capacity has met demand – it’s very difficult to piece together any sort of coherent picture about that. We do know that, however well prepared we may be with beds and ventilators, in many health and social care settings, the PPE provided for staff is atrociously inadequate.

Instead we now seem to be in a morbid competition with other countries on the death rate. It’s not at all clear to me what we are aiming for now. Avoiding overwhelming the NHS was an easy goal to understand and in principle should be easy enough to see whether healthcare demand levels were lowered to an acceptable level or not. But if it’s about deaths now, what’s the threshold of acceptability – how many deaths, over what time period? And what level of disruption to people’s lives and livelihoods (through lockdown) is justified to achieve it?

Meanwhile politicians are still talking about a peak – about being at it or past it – as if it’s not a fragment of an abandoned story about a new virus sweeping through a population and eventually exhausting itself; as if there has been one coherent narrative all along. The paradigm is actually no longer a wave but a plateau, a level of illness prevalence to be maintained until salvation comes through a vaccine. “Peak” is now an admission that things got too out of control; that infections got too high and needed to peak, needed to be brought down again to the acceptable level they should have been managed to plateau at. It’s a negative self-appraisal by the government even if no-one seems to be noticing.

But they won’t tell us what that acceptable level is. I guess it depends what the voting public find acceptable. It’s an awkward conversation that no-one really seems to be attempting. How do we begin to weigh large numbers of early deaths (particularly in the elderly population, does that matter?) against lost incomes, lost education, loneliness, mental health struggles, loss of small businesses that brave and creative people have put everything into, economic ruin that will make life even harder for young people trying to make a life and a living in years to come (we thought Brexit was bad news…!), delays to medical diagnosis / treatment prolonging suffering and creating excess mortality, and so many other problems caused by this lockdown-based approach?

To make matters worse, there is still so much we don’t know. Epidemic modelling is fraught with uncertainty – we don’t have a good handle on how the infection rate would develop over time on its own, let alone with different interventions applied. We will just have to wait and see what happens over time in different places. We don’t know how much immunity is gained from being infected and recovering, or how long it lasts. We don’t even know how much of the population has been exposed to the virus. And we don’t know for sure that there will be an effective vaccine or treatment.

I don’t know what to think and every day I go round in circles trying to understand everything. I think lockdown is necessary until the PPE and testing failings are rectified, but it sucks. Lockdown, failure to protect workers, death – it’s all heartbreaking.

I’m intrigued by Sweden’s approach and the arguments made in support of it. I think my feeling is ideally you either do that – decide to let the epidemic run its course while intervening to protect healthcare systems and essential workers and shield the most vulnerable – or you “go early and go hard” like New Zealand and many Asian countries, make a success of containment with serious contact tracing and testing. (Which approach is better partly depends on which version of the epidemiology is right. It also depends on being able to sustain measures for the long haul – I think it’s far too early to call successes.) Protracted shutdown and prolonged low-level contagion just seems like the worst of all worlds to me, not least for those having to shield – when the fuck are their lives supposed to be able to get back to normal?

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Strategies, national and personal

So here is what I understand…

China, South Korea, Singapore have actually managed to contain Coronavirus, through either really stringent lockdowns and/or painstaking contact tracing and extensive testing. (I suppose the populations remain vulnerable, but any further outbreaks will be contained in the same ways.)

In Europe we either haven’t taken these strategies as seriously or haven’t had the means to do it, so we’re left with trying to manage the spread; we’ve been hearing rhetoric around “delaying the peak” and “flattening the curve” to avoid overwhelming healthcare systems… which is basically an admission that it will have to sweep through the population and infect the majority of people in time. It also implicitly assumes there will be immunity post-infection, as otherwise there would be nothing to make infection rates reach a peak and go down. (Experts seem to think such immunity is likely – let’s hope so.)

Countries differ on what measures they think are needed; countries change their minds; all modelling is provisional and uncertain; but the goal everywhere is really the same, and the problem is no-one really knows what strategies are best once it starts to get out of hand. UK government decided it would be best to allow a (manageable) level of infection to happen, to produce some immunity and reduce the size of a second peak later. Then they appear to have been advised that the infection rate wasn’t going to be manageable after all and we’ve suddenly moved rapidly into a lockdown, from which state we are now waiting to see how right or wrong we have been. It’s hard to find any reason to believe our fate will be different from that of Italy or Spain.

It’s also hard to decide on a personal strategy when you (or someone in your household) is trying to avoid the infection altogether. It might be possible in some cases to put life on hold and hide away from the worst of a single peak, but we seem to be looking at the prospect of a series of peaks and intermittent lockdowns over a very long time. What do you do?

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Time to Talk: therapy, meds, slow confidence and joy

I’ve now been in therapy and on medication for anxiety for about 7 months. In honour of ‘Time to Talk‘ day, I thought it was a good time to write again, not least because I have something very positive to say.

If I think of those moments of grace I mentioned previously as momentary breakouts of sunlight from behind the clouds, in the last two months, it’s as if those clouds have actually dissipated and I’ve been able to bask almost daily in a pure joy I could never have dreamed would ever shine down on me. I love my life lately, and I’m not sure I have ever really felt like that. The contrast from the crisis point in the middle of last year, when I was so stressed and hopeless I (carelessly) said to my partner that I wanted to die, is staggering.

Just the other night my daughter woke at 3am with a highly active mind, desperate to chat, and I simply went and got a book for her – and enjoyed, even savoured, some precious moments looking through the book with her and discussing what was in the pages, before she could settle down again. A small example that I think epitomises how I’ve been able to approach life in this last wee while.

I’m not sure how much of the change is due to therapy, medication, or even just an inevitable personal development. But the therapy has certainly been helpful, much more so than the previous two occasions when I’ve had any. (The 16-month wait was not, though. I only wish I had asked for help earlier.)

I’ve learnt some useful things about myself. One observation is that it takes me a long time to feel confident about my ability to do anything. As an example: I passed the driving test after 6 months of lessons in 2011, but for years afterwards, every time I drove a car without incident, it felt like I’d simply been lucky and got away with it. It took a lot of time and experience to change that.

And it’s been sort of a crucial observation, since the aspects of my personality underpinning the slow development of confidence are also the aspects that set me up for anxiety disorders:

  • Being realistic about my limitations, but also biased to magnify threats and challenges ( => pessimistic about my ability to manage)
  • Control-seeking: I can’t be confident until I have everything mapped out and my ability proven in every aspect or every situation that might possibly come up ( => perfectionism)
  • Very little tolerance for pain or discomfort of any kind, mental struggle, physical effort, etc.; also relevant here is my complete lack of early experience of succeeding at anything through working hard, and the unhelpful sense I developed that ability equates to never finding things hard.

My anxiety, by the way, is often expressed as rage; or even despair when I’m more battered down by it. It’s felt useful to be able to identify that.

I’ve certainly reflected before on how some of these personality traits underlie my health anxiety and vomiting phobia. But it’s now a much fuller picture, sort of a unifying framework for understanding pretty much all my major struggles in life.

How it affects my experience of motherhood is fairly clear from other posts. It’s frequently pushed me to the limits of what I feel I can handle, particularly in terms of sleep deprivation and illness.

How it’s affected me at work is something I can now see more clearly than before. I did have a spell of psychotherapy at the start of my PhD to address work-related struggles, but I didn’t really piece it all together. I have taken on some fairly big challenges over the years; I have consequently spent a lot of time anxious and miserable. I haven’t thrived often and I’ve struggled to understand why.

I’ve often felt guilty for wanting to run away from positions that I’ve been privileged to have; I’ve been so disappointed with myself, considering the hardships others are able to tolerate at work. I’ve felt the same regarding motherhood: ashamed of how much harder I seem to find things than other people.

But after this spell of therapy, I feel more at peace with this reality. I guess it’s partly just being labelled with an anxiety disorder. Labels are powerful – in this case legitimising the difficulties I’ve had. But it’s also the thrilling experience of being able to improve things for myself, through the CBT methods I’ve been shown. (The day I found myself laughing at someone vomiting on YouTube, after watching vomit videos on repeat for several days, was the day I had to restrain myself from dancing down the corridor into work.)

I may have basic personality elements that predispose me to problematic anxiety, but there are ways to manage that; it doesn’t mean I am pathetic, nor does it have to ruin my life. It can even add depth to my life as I learn to overcome these challenges. Because the flip side is, when I do eventually find my confidence, I am unstoppable.

If you ever feel as bad as I did, know that you are not alone, and that there is hope. Don’t be afraid to ask for help.

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