Raghib Ali: Covid-19. The pluses and minuses of the Government’s new plan – and why there should be no more lockdowns.

25 Sep

Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford. He writes in a personal capacity.

Last week, I explained on this site why there is still significant potential for harm from a second wave – both directly from Covid-19, and indirectly from its effect on the NHS’ ability to keep all essential services running.

Today, I will try to address the key question as to what our response should be. The situation now is almost the exact inverse of the one I discussed in June in relation to lifting lockdown restrictions. The divisions remain, and the public health messaging still needs to improve but there is now wider acknowledgement of the need to balance the harms of Covid-19 with those of lockdown.

I wish I had the same confidence as the armchair epidemiologists about the best course of action, but the truth is that although we do now have actual experience of dealing with first waves (as opposed to just modelling), ‘the science’ is still highly uncertain, with conflicting evidence for the effectiveness of different strategies (mitigation vs. suppression) in different countries.

I have set out in more detail on my blog why it is difficult to draw definitive conclusions but, in brief, the evidence we have is generally from low quality observational data which have significant limitations – and so we don’t know for certain if the reduction in disease was due to the intervention or other factors.

Also, many interventions were instituted simultaneously and so we don’t know which had the biggest effect in reducing infection. However, it is clear that the measures taken pre-lockdown (self-isolation and social distancing) did reduce infections and must remain the cornerstone of our response.

Between-country comparisons are particularly problematic as countries differ in so many important ways but I will briefly discuss the experience of Sweden as its approach has attracted so much attention (and supporters and detractors). Compared to its nearest neighbours, it has (so far) had a five to ten times higher death rate with a similar economic decline. This supports the case that those countries that locked down earlier had less deaths from Coronavirus (because they had less cases) – as would be expected given the virus needs human interaction to spread.

However, when compared to the UK, Belgium or France, Sweden has a similar level of deaths with a much better economic performance and has demonstrated that first waves can be ended with measures short of a full lockdown (including, crucially, keeping schools open).

But it is too early to say that Sweden has escaped a second wave as they generally occur about three months after the end of the first and Sweden’s only ended in July. However, I think it is unlikely as they have not reached the 20 per cent antibody level which may provide herd immunity (they are at about seven per cent.)

Also, in general, lockdowns postpone rather than prevent infection (although the death rate should be lower in second waves, due to better treatments) and Israel provides an example of their limitations where they now have a much larger second wave of deaths which has led to a second lockdown. And this cycle of lockdowns would need to be repeated until vaccines / very effective treatments become available – of which there is no guarantee.

Of the large European countries, Germany has (so far) managed the Coronavirus most effectively, with lower deaths in the first wave (and less economic damage) and no second wave yet – which seems to be due to better testing and tracing, and shielding of those at highest risk.

However, it is still too early to say which countries’ strategies are correct, and we won’t know until the end of the pandemic. But, of course, we have to make decisions now based on the best evidence we have.

Although I don’t agree with all the measures, I think the approach outlined by the Prime Minister and Chief Medical Officer – which can be seen as a hybrid mitigation / suppression strategy – is broadly correct ,and rightly focuses on the balance of benefits and harms in order to produce the best overall outcome.

And although there is now broad agreement that we must try to prevent a second national lockdown, there is already pressure to increase the restrictions further.

But before doing this, I would urge the Government and Parliament to ask these three questions:

  • First, how good is the evidence that the intervention works in reducing Covid-19?

We have a much better evidence base now, with the different interventions used over the summer and some data from the ‘natural experiments’ being conducted as devolved nations introduced slightly different measures (e.g. on the rule of 6, size of bubbles, household mixing, etc.)

Measures should also be in place for at least two weeks to assess effectiveness before considering new ones; but should also be reviewed regularly, and not kept any longer than necessary. (The Government should also urgently fund trials to test different interventions in different regions to get better evidence.)

  • Second, is it clear that making these restrictions mandatory (with penalties) makes a significant difference to compliance/ effectiveness of these measures?

In some cases, this is clear (e.g: breaking self-isolation rules where the voluntary system was not working well) but, in general, the harms of (particularly social) restrictions could be reduced by making them voluntary.

  • Third, and most importantly, does it clearly have more benefit than harm in relation to overall health, quality of life, education and jobs?

It is hard to see how a second national lockdown could be justified, even on health grounds, with the Government’s  own health cost-benefit analysis  showing that, in the long-term, the health impacts of the two month lockdown and lockdown-induced recession are greater than those of the direct Covid-19 deaths. (Importantly, this analysis was on the basis that mitigations to reduce Coronavirus infections (e.g. social distancing) were in place – otherwise the harm from Covid-19 deaths was more than three times greater than lockdown.)

Other analyses have also come to the same conclusion – particularly when also considering the economic costs of lockdown – which also harms health and society.

The evidence for the effectiveness of local lockdowns is mixed, but they will still have associated harms – and will exacerbate inequalities and so similar comprehensive, cost-benefit analyses are needed – with the input of economists and educationalists as well.

New lockdowns should only be considered when there is clear evidence of more benefit than harm, and closing schools must be the last resort.

We need to prioritise those interventions that most reduce the direct and indirect harms from Covid-19 (which will therefore decrease the need for more restrictions) while doing the least harm to everything else – particularly other health harms, education, and the economy.

Based on our experience, these are three interventions which could save thousands of lives this time:

  • First, improving the public health messaging and reducing fear. Thousands died and suffered at home either because they thought they needed to ‘stay at home’ to ‘protect the NHS’ even when they were seriously ill – or they were too scared to come to hospital. We need to reassure the sick and ideally provide separate Covid-19 units/ hospitals to give them more confidence to attend – which also means keeping Covid-19 hospitalisations at a low enough level to enable this.
  • Second, ensuring that all NHS services are kept running. while also managing Covid-19. Millions have suffered, and thousands will die, through the closure of NHS services – which we now know was not necessary and mustn’t happen again. We must urgently establish the level at which Covid-19 admissions will overwhelm the NHS – not in the sense that we used before (i.e. emergency and critical care) – which is no longer a risk – but all other essential services as well. And this time, we must use the increased capacity available from the Nightingales and private hospitals.
  • Third, protecting those at highest risk including care home residents and hospital patients with regular testing & isolation, and ‘smarter shielding.’  This can be much better targeted now with all the data we have and individual ‘Covid-19 risk calculators’ should be urgently rolled-out to help people understand their own risk and make their own informed decisions. It will also help people to overcome their fears and seek medical help when required, as well as help to reduce Covid-19 disparities.

I do not, however, believe this shielding should replace the other measures to suppress the virus in the general population. There is currently not enough evidence to show that it is possible to effectively shield all those at high risk or to reach herd immunity without significant direct harm to the lower risk groups where adverse health effects occur in about a third of cases, including the young and those with mild symptoms.

(Of course, test and trace is also critical – and there is certainly room for improvement, particularly in schools, but the UK does have one of the highest testing rates in Europe.)

The public have the most important role of all in controlling the virus, and so must be convinced to follow the current restrictions and given support, as needed, to do so. To improve public consent and compliance, the Government should publish and explain the evidence – and be honest about the decision-making process, the uncertainties and the trade-offs.

The coming months will be challenging for all of us, and we will need to learn to live with the virus and change our behaviour accordingly. For some, that will mean reducing our social contacts; for others – overcoming our fears; and for all, looking out for the vulnerable, being patient and making sacrifices for the common good.

Finally, having served on the front-line, I am only too aware of the death and suffering that Covid-19 causes – but the harms of a second lockdown would be greater. And so we must follow the current measures and by protecting society, education and the economy – as well as the NHS – we will save, and improve, the most lives.

Raghib Ali: Evidence suggests that this Covid second wave won’t be as severe as the first. Nonetheless, it’s a threat to the NHS.

18 Sep

Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.

It is three months since we started to leave lockdown and, while we have learnt a lot about the virus in that time, the key questions I discussed then remain. What are the risks of a second wave? And what should the appropriate response to it be?

On the first question, the debate remains as polarised as ever – with two widespread misunderstandings of the data. The first is that cases are now as high as they were during the first wave – leading to unnecessary fear – and the second is that hospitalisations and deaths (and test positivity) are much lower now than when we had a similar number of cases – leading to unjustified complacency.

These case count (and test positivity) comparisons are completely misleading, because far more tests are being carried out now than in the first wave when they were only being done on those is hospital, not in the community.

Therefore, the number of recorded cases were a huge under-estimation – the actual number of cases at that time is now known based on antibody testing. Roughly seven per cent or four million people have had the infection in England, and daily case counts can be inferred based on this, as well as working backwards from the resulting hospitalisations and deaths. .

We are now at roughly 3000 cases a day on the basis of positive tests (the true number is about 6000 based on the ONS survey, with about 40000 cases in the last week). This is about three times higher than the trough in July but less than five per cent of the peak in March (when there were about a million cases a week).

So while there is certainly no need to panic based on case count, those who are only looking at hospitalisations and deaths are also in danger of being falsely reassured. At the beginning of the first wave, it took less than three weeks to go from 6,000 cases a day on March 5th (50 recorded cases) to 300,000 cases a day on March 23rd. (2000 recorded cases). There was only one death on March 3rd, but a month later it was a thousand a day (with 3000 admissions).

The key point is that the situation can change very rapidly and there is no room for complacency. By the time hospital admissions and deaths are going up rapidly, it is too late.

We can also learn from other countries’ experience – again, the evidence is mixed and you can come to different conclusions based on which countries you look at.

However, generally it is true that those countries experiencing large second waves after lifting lockdowns are those that had small first waves so more of their population remain susceptible to infection. But it is not true that the second waves are only causing cases and not deaths (for example, Romania, Israel, Morocco have had far more deaths in their (ongoing) second waves than their first.)

The converse is also true (so far) in that countries with large first waves are having smaller second waves, and particularly in cities like New York where about 20 per cent of the population has developed antibodies, there is no second wave. This latter finding was surprising, as it was expected that herd immunity would develop at a minimum of around 50 per cent of the population being infected, but there is now some evidence that many more people are immune as they have developed immunity from other parts of the immune system or from previous infection with common cold coronaviruses, and this is not detected by routine antibody testing.

However, there is also an exception to this experience: Iran – where a large first wave of deaths has been followed by an even larger second wave (despite about 20 per cent of its population being infected in the first wave), and so we can’t be that confident as to what will happen here.

In general, second waves of cases have started about three months after the first wave and Spain is probably the best guide for us having had a similar level of infections, deaths and immunity in their first wave. Their second wave started about a month ago, and hospitalisations and deaths have now also started increasing – but at a much lower rate than in the first wave.

There has also been significant disagreement about how deadly Covid-19 is – with some incorrectly asserting that Covid-19 is no more deadly than flu. We now have much better evidence with actual data (as opposed to modeling) for the infection fatality rate (IFR) – the percentage of those infected who die (not just those who are diagnosed as positive cases) – with most estimates between 0.5 and 1.0 per cent – whereas flu is less than 0.1 per cent.

Further evidence for this comes from New York, where about 20,000 died – an IFR of 0.1% would mean that 20 million had been infected – but its population is only three million.

The IFR also varies hugely by age (in children and young adults it is almost zero whereas in the over 65s it is above five per cent) and by country, due to differences in the proportion of the elderly, levels of chronic disease and the provision of healthcare.

In the UK, we now have good evidence from death certificates that Covid-19 was the underlying cause of death in about 50,000 people – it’s not that they died just ‘with Covid-19’ – which tallies with my own experience on the front line back in April. And most estimates for the IFR in the UK have been around one per cent, but it may be half that due to undetected infections.

So where are we now? It is clear that our second wave has started (about a month after Spain, as expected) with cases now doubling roughly every seven to eight days (whereas in the first wave it was every three days – with deaths following the same pattern three weeks later.) Hospital admissions have also doubled over the last two weeks.

In the UK as a whole, we are nowhere near herd immunity (we are likely to be at about 15 per cent maximum) and so we are possibly about a third of the way through the epidemic.

It is therefore theoretically possible that another 100,000 people could die from COVID-19 in a second wave in the coming months. Reports from SAGE and the Academy of Medical Sciences also suggested 85,000 and 120,000 respectively in reasonable worst case scenarios.

However, a repeat of the first wave is very unlikely, as cases will increase more slowly due to the measures now in place including social distancing, masks, hand washing; the massively increased community testing (although clearly not enough) which provides local data to target interventions earlier, and allows tracing and isolation of contacts – plus the fact that we have a higher population level of immunity.

Hospitalisations and deaths should also be significantly lower due to the lower age profile of cases (although antibody testing shows that even in the first wave the highest proportions infected were young adults and the lowest were those aged over 65); better shielding of those at highest risk and possibly a lower viral load  due to social distancing and masks.

We are also now much better at managing the disease with more effective treatments. Another factor that should reduce overall excess deaths this winter is that the flu season may be much less severe than usual due to coronavirus measures – as has been the case in Australia.

But it is also important to realise that although the NHS wasn’t overwhelmed by Covid-19 cases (in relation to ward and critical care bed use) in the first wave – and this is something I’ve only appreciated recently – NHS services as a whole were overwhelmed.

The only way the NHS was able to cope was by shutting down many essential services which caused suffering and death for thousands – particularly cancer patients – and huge increases in waiting lists. Therefore, it is essential to keep Covid-19 cases / hospitalisations at a much lower level this time, so as to ensure that all essential NHS services keep running – or we again risk thousands of additional deaths.

In conclusion, sadly, the pandemic is far from over and a second wave has the potential to cause very significant direct and indirect health harm. Doing nothing is clearly not an option – but neither should a second lockdown be, as I will explain on this site next week.

Raghib Ali: Systemic classism, not racism. Why the main factor in health and educational inequalities is deprivation, not race.

21 Jul

Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.

Last month, it was widely reported that Public Health England’s report,Beyond the Data: Understanding the Impact of COVID-19 on BAME Communities, proved that systemic racism had contributed to their increased COVID-19 death rate.

This report, coming out as it did during the fallout from the horrific murder of a black man by a white police officer in the US, was used by some as evidence that ‘Britain is a racist country.’

The report itself was more nuanced, saying: “racism, discrimination and social inequalities…may have contributed to the disproportionate impact of Covid-19 on people from black, Asian and minority ethnic (BAME) backgrounds.”

While it is true that the death rate for Covid-19 is higher in non-whites, the analyses presented did not account for the effect of occupation or comorbidities. The current evidence is inconclusive and most of the increased risk can be accounted for by known risk factors, including co-morbidities, deprivation, higher risk occupations, living in densely-populated urban centers, air pollution and multi-generational households.

In fact, the claims about racism were based on the subjective views of 4000 ‘stakeholders’ – not on objective evidence – as the report itself acknowledged. Although it is possible that racism  contributed to some of the risk factors, this certainly does not prove that racism caused Covid-19 deaths, and such inflammatory claims should not be made without solid evidence.

Also, if it were true that non-whites suffer from systemic racism throughout their lives – adversely affecting their health, education, income, housing, employment (the key determinants of health) – this would be reflected in life expectancy/overall mortality figures which are the best measures of overall health.

However, (in contrast to the situation in the US, where Blacks do have lower life expectancy) non-whites in the UK actually have higher life expectancy / lower overall mortality than Whites. In Scotland life expectancy (LE) is higher in Indians, Pakistanis and Chinese than Whites, and in England and Wales, both Blacks and Asians have slightly lower death rates than Whites, with those born in Africa, the Caribbean, and South Asia all having lower overall and premature mortality than those born in the UK.

This finding is surprising as some ethnic minorities are much poorer than Whites – with over 30% of Pakistanis & Bangladeshis and 20 per cent of Blacks living in the most deprived 10 per cent of areas (versus 10 per cent for Whites & Indians)  and deprivation is the main factor associated with lower LE. Those who live in the most deprived areas of England (predominantly in the North) live on average 10 years less compared to the least deprived (25 years between Blackpool and Westminster) – the gap is even worse for healthy life expectancy where the difference is 20 years on average (33 years between Blackpool and Westminster) and this gap or social gradient in health is seen within all major ethnic groups.

This gradient was also seen for Covid-19 where, amongst non-whites, the most deprived were four times more likely than the least deprived to require intensive care, again illustrating the need to focus on deprivation.

We see a similar picture when it comes to education – which is both a key determinant of health and hugely affected by deprivation. The Race disparity Audit showed that, when looking at outcomes by ethnic group alone, Indians & Chinese outperform other ethnic groups, including Whites, at every level of education while Black Caribbean children perform worst – and significantly worse than Black Africans – except for university entry where Whites have the lowest rate (although they then do go on to have the best degree and employment outcomes.) 

Once deprivation is taken into account – by comparing only those on Free School Meals (FSM) – White and Black Caribbean children have the worst outcomes on almost every measure and especially university entry. (Although there are again huge regional variations – 48 per cent of inner London FSM children v 18 per cent in the South West.)

Children from ethnic minorities are now also more likely than Whites to attend grammar schools whereas just 2.6 per cent of their students are on FSM (compared to 14 per cent of the population.) Even for Oxbridge entry, non-white students are now as likely as Whites to gain entry whereas those on free school meals have almost zero chance.

This was also my experience as a student at Cambridge where it was not my ethnicity which made me stand out as much as the fact I had been on FSMs. There were many non-White students – but invariably from middle-class, private or grammar school backgrounds – whereas there were barely any  deprived students of any colour.

Deprivation, therefore, is the key factor driving educational inequalities with children of all ethnicities on FSMs doing much worse than those who are not.. But again, we see that some groups (Pakistanis, Bangladeshis and Black Africans) – despite being more deprived than Whites and Black Caribbeans – have better educational outcomes.

Based on this data, I draw three broad conclusions.

Firstly, the primary factor in health and educational inequalities is deprivation, not race.

Secondly, there is now no overall ‘White privilege’ in health or education (and especially not for deprived Whites) – or overall ‘BAME disadvantage’ – and these categories are now outdated and unhelpful. There are large differences in both health and educational outcomes between & within ‘Blacks’ and ‘Asians’ – with the biggest differences seen within Whites. Deprived Whites actually have more in common with deprived non-whites in terms of the challenges they face in education, employment, housing and health.

Thirdly, where ethnic disparities do exist (e.g. employment, promotion, criminal justice, etc.) we must take deprivation into account (i.e. compare deprived minorities to deprived Whites) – otherwise it is easy for some to blame racism when poverty may be the main factor. This also applies to those who, while rightly highlighting the plight of the white working class, blame ‘positive action’ towards ethnic minorities without presenting any evidence.

While I fully support the objective (if not always the means) of the young people demonstrating to eradicate racism, I have found that many of them are neither aware of these facts nor of the massive progress that has been made. Growing up in a white working class neighbourhood in the early 80s, we suffered racist abuse and attacks – with one of my earliest memories being of a brick being thrown through our front window. (But I knew they only represented a small minority and all my friends were also white).

My father had also faced open racial discrimination from the time he arrived in the early 1960s, but my parents never encouraged us to view ourselves as victims and stressed that education and hard work were the keys to a better future, with my mother – who enrolled in evening classes to gain additional qualifications while working full-time – as our inspiration.

Racism still blights too many lives today and we must we must continue to work towards a colour-blind society but Britain is not a racist country and what has been achieved in my lifetime is remarkable with my children growing up in a country transformed. Enoch Powell has been proven wrong – the UK is one of the most successful, multi-ethnic nations in the world, with huge, positive changes in social attitudes. Ethnic minorities are now well-represented – and successful – in almost every walk of life including medicine, business, sport, culture and politics. And this has been achieved without positive discrimination or quotas which ignore root causes and can be counter-productive – patronizing minorities and leading to resentment.

Unfortunately, there has been far less progress for the poorest in society – of all ethnicities – with evidence that gaps in life expectancy are worsening and social mobility is actually going backwards.

I therefore welcome the government’s ‘Levelling-up’ agenda to address the huge geographical variations in deprivation, health and education. These inequalities are longstanding and will require long-term solutions with better educational opportunities – particularly in the early years – being the key to breaking the cycle of deprivation and ensuring that everyone has the best possible start in life.

We can learn from those inner-city schools in London, which despite serving highly deprived (mostly non-white) populations, are producing outstanding results. And we should investigate why these deprived groups are doing better than others – including exploring the difficult terrain of whether cultural values, higher marriage rates and more stable homes are contributing to better outcomes.

In conclusion, we need geographically-targeted policies and interventions based on need, not ethnicity (but which will actually help those ethnic groups who have the highest levels of poverty the most – including deprived Whites.) Because the greatest determinant of your life chances today is not the colour of your skin but the circumstances into which you are born – and we must tackle this enduring injustice of ‘systemic classism’ to create a fairer Britain for all.

This piece originally appeared on ConservativeHome on July 21 2020, but we re-run it as a contribution to this week’s series on the politics of race and ethnicity in Britain today.