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?