Hi Michel, 

please see below my reply to your email,

 I am delighted that you have put an emphasis on the excess mortality, something I believe to be an important (and perhaps the only reliable) measure of what's going on. Perhaps we can have a meaningful discussion on this common factual base and its progression, and its significance.

I’ve quoted excess deaths back to you because you don’t trust official statistics regarding infections based on the PCR test. The problem is that excess deaths are a lagging statistic and can’t be used for predicting the future and taking decisions. Covid deaths occur at least two to three weeks after infection and deaths up to 28 days afterwards are also counted. Collating statistics on deaths from all causes takes time as well.

 I have been monitoring this statistic. Its growth, albeit a long time after the dramatic rise in so-called cases, is concerning. My difficulty is in whether the size of it warrants the reaction we have seen. Such events occur regularly - more or less annually with the flu-

The definition of “excess mortality” is the number of deaths that is higher than is normal for the time period in question. “Normal” is established by taking an average of “normal years“.  Unless there’s a new strain of flu virus, annual deaths from this cause would be considered normal and would be included in the average.  If there is an unusual situation like we have now, such as a new virus or a major heat wave, then, as you know, the excess deaths are calculated by taking the totals over a chosen period of time and comparing them with averages from ”normal” previous years. Therefore annual seasonal deaths from flu would not be counted in any calculation of excess deaths.

 - they come and they go, and we do not see fit to bring the economy to its knees, or to cancel normal human contact.

For me it's a question of proportion, and a question of individual responsibility.

I disagree with this. It isn’t just a matter of individual responsibility because there will always be reckless and misguided people who choose not to take simple precautions and therefore present a risk to others. Look at the crazy situation in the USA!  In spite of the best efforts of some politicians, like Nigel Farage, to stoke distrust in government, in Western Europe people expect their leaders to act in the population’s best interests. Can you imagine the outcry there would be if governments did nothing and hospitals were overwhelmed with ambulances queuing outside and people dying on trolleys in corridors.

 If we find that the virus starts killing vast quantities of young fit people, that would alter my perspective.

You are focussed on deaths because they are counted and reported but you’re ignoring the debilitating longer term effects that many people, including younger fitter ones have experienced with Covid 19. These are much worse than being “confined” for a few weeks. Recent estimates put the number of such cases at 10% of those infected. Furthermore there’s no way at present of predicting who will suffer “long Covid” and who will breeze through it with no long term effects.

 But while this concerns largely the old (of which I am one) and sick, I prefer to privilege the lives of the young and the economy which will have to pay for their health in years to come, and I want people who feel themselves to be at risk to take suitable precautions. 

As I’ve stated before and supported with a reference, there cannot be a normal thriving economy if a serious public health crisis is rampaging through the population. People will take action to avoid catching the virus and reduce their risk of exposure. So some sectors of the economy will suffer as a result. The only way of avoiding this without lockdowns is to reduce the circulation of the virus by vaccination. Fortunately early trial results are showing several vaccines to be over 90% effective. But less encouragingly in Le Point of 29/12//2020 there’s an article which states that only 40% of the French population would take up the vaccine! 

Most people are generally hopeless at assessing risk and it seems that the vaccination sceptics are more afraid of a vaccine than a potentially dangerous illness! Perhaps they just don’t want to be “Un des moutons de Panurge”. If more than half of the French refuse to be vaccinated then there will be no herd immunity and it’s time to say a fond farewell to communal life as we used to know it and buy shares in undertaking firms.

 I find in any case that people are responsible, and are busy taking their own decisions - I don't know a single person, old or young, who follows the restrictions to the letter - we each find our own level of compliance, even if we count ourselves more or less in the camp of accepting the government response. 

Actually we do know several people who are following the rules even if we aren’t completely. This lockdown episode is a bit of a joke anyway because there is so much activity it’s hardly a lockdown at all. I would, however, like to have a haircut before Christmas.

Whatever this latest rise in mortality is, it is not the same as the first wave. There has been more than a 2 month delay, rather than the 2-3 week delay we saw at the outset. That might in fact be a very bad sign indeed - if the dramatic rise in cases that started 2 months ago is reflected in the death count now and in the weeks to come, that will be horrific, but it will take its course whether we lock down or not. I suspect that that will not be the case, but as you said before, we'll see.

In my opinion in March there were many many more Covid 19 infections than were ever recorded and reported. We know three people who caught it just before lockdown and never went near a doctor. They were lucky and had mild-ish versions.

It’s not possible to know how many people were actually infected in March, but as an illustration let’s assume it was ten times as many as the official test results showed. The death rate per thousand infections would therefore be a tenth of the rate calculated based on positive test results in March. 

If one now takes the numbers of positive test results in October/November, and applies the same death rate per thousand, you would get a much lower number of deaths than in March/April. This may be an explanation for the apparently lower severity of the virus in the second wave.  There is also, this time round, the availability of therapeutics and better knowledge of how to treat serious cases.

Personally, I’m already waiting for a flu jab and as soon as a vaccine for Covid 19 is available I will have one!

 

 

A Second Wave in Europe

After a quiet summer Covid 19 infections are rising again and there is a surge in reported positive test results. In many countries in Europe restrictions are being progressively introduced which limit rights of assembly and affect businesses.

There are people, including some politicians and experts, who believe that this surge in reported cases is a result of the increased availability of testing, and still others who think that the tests used are too sensitive. They consider that the current tests over-report the incidence of the virus. This opinion has been picked up and amplified by social media to support the view that the measures taken to limit the spread of the virus are an over-reaction.

The surge is accompanied by an increase in hospitalizations and an as yet smaller increase in deaths associated with the virus, but since these are bound to take longer to become evident, they are not increasing as rapidly.

The PCR Test

The most commonly used test for Covid 19 is the PCR (polymerase chain reaction) test. This amplifies any virus RNA found on samples by going through numerous cycles of replication. The outcome of this process is that the tests are very sensitive and will detect very small amounts of virus. Some experts have been mis-quoted as saying that this results in 90% false positives and therefore the overall numbers of people testing positive is greatly inflated.  This is incorrect, but there is an ongoing debate among experts as to how many cycles should be employed before declaring a test positive or negative. 

False Positives

By definition if the test finds Covid 19 viral RNA it is a correct positive result regardless of the initial quantity of virus present and the number of cycles of replication. What the PCR test can’t do, however, is to determine whether an individual is infectious. This is done by clinical examination to try to ascertain whether an infected person is displaying symptoms that have been found to be correlated with infectiousness.  So since there is no test which predicts a patient’s response to infection by the Covid 19 virus and their infectiousness, anyone testing positive is advised to self isolate and wait out the course of their illness.

The Rate of Increase of Cases

It's obviously important for individuals who think that they are likely to have been infected to know their test status; so that they can take the steps necessary to protect their families, friends, colleagues and others. However, on a larger scale the exact total number of positive tests doesn’t matter.  It’s sufficient to see the exponentially rising trend, which is currently showing itself in several European countries including France and the UK.

Whilst one can argue about whether tests are correct or not, eventually the real world will intervene. We know that the rising rate of infections is already leading to a rise in hospitalizations. As an example, in Paris  at the 10^th October 2020, the rate of tests returning positive results is 15.27% and the occupancy of intensive care beds is 39.1%. The latter is predicted to be at 100% by the end of October. There will inevitably be, in my opinion, a rising death rate in the near future as well as further restrictions.

One can only hope that improvements in the knowledge and treatment of Covid 19, and the availability of therapeutics, will reduce the incidence of severe illness and death for those unfortunate enough to have caught it. One can also hope for the early availability of effective vaccines which give long term protection, but regrettably we don’t know yet how long any immunity conferred by a vaccine, or even a previous infection, will last.

Is it time we learned to live with the virus?

When the Covid 19 virus first appeared almost everyone was unprepared. Some governments like China, South Korea and Germany did better than others; they reacted quickly and took control. The result was that they had fewer cases, fewer people with serious illness, fewer deaths and less severe economic effects.  Other states like Italy, Spain, the UK and France had leaders who were slower and less capable of reacting to the situation before they had a severe outbreak resulting in tens of thousands of deaths. Still others, like the leaders of the USA and Brazil, refused to take the disease seriously and actively attempted to minimize its impact and consequences. In some cases this was in spite of their knowledge of the true facts. They preferred to prioritize the politics of the pandemic rather than listen to their scientific advisers and we can now see the results of that in death rates.

Following the example of China, Western governments almost universally instituted drastic confinement measures to slow down the transmission of the virus and prevent a situation in which hospitals were overwhelmed and people were dying on stretchers in car parks. On the whole and despite the high number of deaths this was a qualified success. It reduced infections drastically and people did comply with the draconian restrictions, in spite of the very severe economic consequences.

The second wave.

Then, as the virus declined in Europe in the summer, we all relaxed and started mixing normally, crowding onto beaches and having parties. So of course the virus came back and is now circulating freely and reproducing exponentially in many places, including France and the UK. Whilst infection rates are high, death rates are low at the moment, but they will increase after a lag period of a few weeks.

Fortunately, and although it is less than perfect, as a result of the increased availability of testing we now know much more than we did before about the geographical spread of the virus, and can identify hotspots where infections are spreading more quickly than in other areas. This allows politicians to try a more graduated and localized response. It remains to be seen whether recent relatively minor restrictions, like restricting social events and closing pubs and bars at 10pm will make any difference. It should be said that the rate of testing is very much higher than it was in March and April and so many more active infections are now being identified and reported.

Whilst the UK government appears to be reacting on the hoof to day to day changes and not communicating clearly, France has set out an alert system, based on infection rates, which will trigger progressive local restrictions decided by the Prefecture of each Department. At the same time, under their new Prime Minister Jean Castex, they seem to be downplaying the extent of the rise in infections and prioritizing keeping open schools and the economy.

Is it time we learned to live with the virus? 

In my opinion that's exactly what we are in the process of doing now, and only time will tell if less restrictive measures than were applied earlier in the year will be effective. So what is there still to debate?

Some people resent the restrictions on their freedoms to circulate freely and carry on as before. Others are very cautious about social mixing. Some people deny the existence of the virus altogether! Still others are concerned about the damage done to individuals and the economy by movement restrictions and lockdowns.

An impossible balance.

In my view the choice between voluntary or compulsory measures comes down to politicians attempting to strike an almost impossible balance between the needs of individuals to maintain their freedoms; the need to allow economic activity to continue; and the need to protect vulnerable people at greater risk of severe illness or death. Also let’s not forget that even young and fit people can find themselves incapacitated and unable to work months after overcoming the original infection, the so-called Long Covid.

It is the mindset of the individual which determines whether they value their own freedoms to such an extent that helping others to stay clear of infection by accepting constraints is much less important to them. Individuality versus Solidarity. In consequence there will always be people who are dissatisfied with any restrictive measures that are imposed or who consider that they have not been taken early enough.

Striking this balance also concerns the perception and evaluation of risks, about which most people are highly irrational. I’m glad that I’m not a politician charged with the task of weighing all these considerations. Sometimes I almost feel sorry for them, but not for long!

I have no time whatsoever for people who deny the existence of the virus altogether and prefer to believe in a worldwide conspiracy theory to explain the deaths and testimony of victims. Unfortunately there is a significant number of them!

Lockdown versus freedom and a thriving economy

Presenting free movement and lockdown as alternative responses to the pandemic is, however, a false comparison. I don’t think that a nation can have a functional and thriving economy in a situation where a dangerous illness is circulating freely. People will seek to avoid and minimize their risks by working from home; by not using public transport; by not going to concerts, the theatre or restaurants; and by stopping unnecessary shopping trips and travel. Various sectors of the economy, and their employees, will suffer severely as a result. This is continuing to happen even though lockdown was lifted long ago.

The Swedish example.

The experience of Sweden, which with some restrictions kept everything open, can be quoted to deny this viewpoint, but Sweden is a country with a high standard of living. It’s not overcrowded and has notoriously reasonable inhabitants who have a high level of trust in their government. It’s very different from the overcrowded cities of Southern Europe, South America or India. Even so up to the 22^nd September 2020 Sweden had a total number of deaths of 5,877 for their 10.23 million inhabitants compared with a total of 1,253 for their neighbours Norway, Finland and Denmark who have a combined population of 16.76 million and followed a lockdown policy. Is that a success? I suppose it depends on what value you put on human lives compared to economic losses.

Conclusion

In my view, both from a health and an economic standpoint, it’s in everybody’s interests to reduce the circulation of the virus. So if that means accepting restrictions on my freedom to travel and socialize that's fine with me!

Roll on the availability of an effective vaccine!