Archive for the ‘Health & Wellbeing’ Category

The COVID-19 pandemic is one of the major challenges of our time. Many of us would advocate for evidence-based policy: we should let science guide us on the best course of action. Unfortunately, a complete lack of evidence for our current approach means the way forward is unclear.

The evidence for the lockdown

At first glance, it seems self-evident that implementing a lockdown will reduce deaths. If we all stay at home, it will reduce the transmission of the disease. In theory, this should allow us to spread the disease out over a longer period, and thus avoiding the healthcare system becoming overwhelmed.

Unfortunately, the evidence does not support this view. A Cochrane Review from 2011 concluded “there was limited evidence that social distancing was effective, especially if related to the risk of exposure.”

At the moment, we don’t even understand how dangerous COVID-19 is. As Dr John Lee notes in his article in The Specator, the lack of testing means the mortality stats are meaningless. We’re comparing deaths to confirmed cases, but the untested cases are anywhere from three times as many to three hundred times as many if a recent study by Oxford University is to be believed.

This is confounded by COVID-19 being a “notifiable disease”, meaning that a death could be reported as COVID-19 when a patient actually died of something else. This seems highly plausible given the average age of COVID-19 deaths is 79.5.

As Professor John Ioannidis points out, due to the lack of evidence, the policies we implement could hinder rather than help.

School closures, for example, may reduce transmission rates. But they may also backfire if children socialize anyhow, if school closure leads children to spend more time with susceptible elderly family members, if children at home disrupt their parents ability to work, and more. School closures may also diminish the chances of developing herd immunity in an age group that is spared serious disease.

Even if we somehow did concede there was some evidence for social distancing, we do not need to confound this idea with a lockdown. You can implement social distancing: such as getting people to work from home and banning large gatherings, without implementing a lockdown in which nobody is allowed to leave their house.

Further, even if social distancing did turn out to reduce infection rates overall, we need to look specifically at how it affects the elderly and vulnerable. It could be that young healthy professionals can lock themselves away and avoid infection, but those who require carers coming in and out of their home, or those who need regular medical appointments, cannot. Another example of how social distancing can harm, rather than hinder because the natural immunity we would otherwise develop from the age-groups at the least risk is never built up.

Ultimately, then, the evidence for social distancing is not substantiated. It could be that the models from Imperial College London are correct. But they may also be utterly incorrect. And that is serious as I will explain below.

Social costs of a lockdown

A lockdown is a serious thing in itself. It violates both Article 3 and Article 13 of the UN Declaration of Human Rights. If you are a Brexit-voter who supported leave because you were tired of human rights, you might like the sound of that. But most of my friends are fellow lefties who quite like human rights.

You could argue that is worth it temporarily to protect public health. And maybe it is. But we need to take all of the consequences into account.

These vary from the (arguably) mild: people have had their lives put on hold. They are not allowed to do the things they enjoy, like seeing the people we love. And doing the things we love: whether that is music festivals, triathlons, pub quiz nights or basically any hobby that doesn’t involve sitting on your sofa.

And continue up to the very serious:

• Children are being stripped of their education. It’s impossible to expect parents to homeschool to the standard of professional teachers, and so much of education is the social education of interacting with peers and the school system.
• Some children only get hot meals in school.
• University students who are paying £9,000 per year tuition fees are not receiving their education
• The cost to people’s mental health of being socially isolated and not going outside as much.
• The resulting increase of suicides.
• The transfer of healthcare resources from other conditions to COVID-19. Doctors and dentists are no longer offering appointments and operations for non-life-threatening but nevertheless debilitating conditions have been cancelled
• The tidal wave of anxiety from people wondering whether they have a job tomorrow, or already having lost their job
• The self-employed who find their income has suddenly disappeared and that they are not eligible for government support (which covers nowhere near 95% of self-employed people as the Chancellor claimed)
• The already-overstretched police services admitting that they will only be investigating the most serious crimes because they will be too busy enforcing the lockdown
• The domestic abuse victims who we have locked in a building with their abuser, and given their furloughed abuser nothing better to do than sit around and drink.
• Drug and alcohol users who are in recovery but now more likely to relapse.

These are really, really bad.

People who have flouted the social distancing rules have rightly been called callous towards more vulnerable members of society. But we need to be careful not to fall into the same trap. To dismiss the social costs because our mental health is not suffering, because we have not lost our job, or because we don’t have children who spend years working exams they are now not allowed to take, nor even say goodbye to their lifelong school friends, is a privilege many other people in society do not enjoy.

As Lee puts it, “the moral debate is not lives vs money. It is lives vs lives. It will take months, perhaps years, if ever, before we can assess the wider implications of what we are doing.”

Weighing up the costs

Some young people have died from COVID-19 and that quite rightly tugs the heartstrings. But emotion is very different from evidence. And the evidence from Oxford University shows that the average age of those dying is 79.5.

Life expectancy in the UK is 81. That’s a loss of a year and a half, which is a serious and significant difference. I would be heartbroken if I lost my grandmother 18 months prematurely.

But we have to weigh that against the real and serious damage we are doing to everyone in society. Imperial’s modelling, which has formed much of the basis of the current strategy, predicts that social distancing and lockdowns will have to continue intermittently but indefinitely while we wait for a vaccine. Said vaccine will take at least 18 months to develop, even if everything goes smoothly, and that is before we even start the even bigger hurdle of global immunisation.

If we truly are looking at a 2+ year timescale, the cure would seem worse than the disease. With the average life expectancy of a COVID-19 victim only being 18 months, the majority are likely to die of natural causes in the meantime, doomed to be cremated at a funeral that nobody is allowed to attend.

Worse still, it may be that, as many commentators have predicted, social distancing and lockdowns are not sustainable for such a long period of time. As a result, the pandemic will continue to flare up and kill just as many people, and all our suffering will have been in vain.

If the pandemic magically goes away in the next 12 weeks, then you can make a solid case for the lockdown. And let’s pray that it will. But if not, and we have to keep the suppression methods in place until the vaccine arrives, or they simply fail, we will have wasted more of everyone’s lives than we saved for the 0.25-1% of people who, already at the end of their life, had it cut slightly shorter.

Ultimately, we do not know what the correct answer is. A lack of testing and a lack of data means the conclusion is unclear. And yet, based on that, we are implementing a policy with dire consequences for education, mental health and quality of life.

Editing notes: reflecting back, I’m not sure 81 is a fair assessment of life expectancy. Although it is the average life expectancy in the UK, once you reach 79.5, you are likely to live longer than 81. How we adjust for this is unclear, though. The ONS suggests that a 79-year-old will live another eight years. But this is for a typical person, and we know that most people survive the virus but that rates of mortality are particularly high for people with underlying health conditions. Therefore, in order to adjust, we would need to know the life expectancy of a 79-year-old with underlying health conditions. Unfortunately, that is data we do not have.

At first glance, yesterday’s figures do not look too bad. Both Italy and Spain seemed to have stopped shooting up. But the provisional figures from today (Friday) mean that they are both going to set new heights tomorrow.

It’s a bad day for France and the UK, too, who both had record days.

Here is the other big change: I have also started tracking Netherlands. Why? Because Netherlands are sticking hard to the herd immunity strategy. This was mentioned in the UK and, depending on who you believe, was always a side-effect of the plan, or the plan until Johnson’s critics spooked him into adopting the current approach. Tracking Netherlands may provide some evidence as to how effective the lockdowns are.

Let’s look at total deaths.

The first thing to explain: I have now capped this at 60 days, rather than expanding it as the dataset grows. This makes it easier to see the curves in the early days. It does mean we are now missing the past five days from China. But the line is basically flat (they are still having a handful of deaths per day, though).

Second thing: I have included the UK’s provisional figures from today in the report. That makes the graph look much scarier. We are the blue line. Until this point, we could hold out some hope that our line would follow the green line (China) and not the red line (Italy). But at this point, it looks like we are accelerating on “the European trajectory” as we could call it.

And, to state again, the UK is ahead of almost every other country was on day 15. This includes Italy. Spain is the only exception, who are way ahead of everyone. Ignore the single dot from Netherlands, that is erroneous data. Currently, they are roughly in line with other European countries.

It was a bad day for Spain yesterday who reported more deaths than Italy. Italy, on the other hand, maybe showing signs of levelling off. The UK had a fairly good day, but that may be due to underreporting: the BBC said the timeframes were chopping and changing, which might explain why we had few deaths yesterday but over one hundred today.

Here is the new graph for today. It shows cases across England broken down by NHS region, with the separate nations (Scotland, Wales, Northern Ireland) also getting their own slice of the pie.

A third of the cases are in London. But that is not abnormally high: they have 13% of the population and the most international travellers passing through. Still, might make you think twice before taking the tube. Otherwise, it is fairly well spread out across the country.

I mean, we have definitely had better days. Spain, France, the UK and the United States all had their highest ever death count yesterday. And bear in mind that I am only tracking seven countries. But there is a silver lining: although Italy had a bad day, too, it was not as bad as two days ago.

It is still too early to say whether the UK is going to follow Europe or China. But it would seem odd if it did follow China given we have been taking at best similar, and at worse, much more lax measures than the rest of Europe, while China went into lockdown early and did a lot of testing.

The problem is that we are still earlier on in this than everyone else. We’re on day 12. Italy is on day 29, Spain is on day 17 and France is on day 18. At this stage, everyone except Spain was behind us. Early indications from the NHS is that today wasn’t too bad, but it’s only 9pm, so we’ll have to wait and see.

I’ve updated the graphs for today. WHO report on what happened yesterday, so when I say today, I mean the data the WHO published today, but it’s actually yesterday’s data. And yesterday wasn’t too bad. Italy continued to decline for the second day in a row. And when I said the borderline for good for the UK was 331 deaths, we came in at 335, so pretty close.

That said, based on today’s media reports, we know that the UK, Italy and Spain are all having a really bad today. So, tomorrow the graphs are likely to look terrible.

Anyway, onto today’s graphs. I took the figures from Imperial College London on the likely mortality rates of COVID-19. These are adjusted based on many cases not being reported, and for a UK/US healthcare system.

I want to preface the following by sating: just because you have a low risk of dying, does not mean you can go around doing whatever you like. You can spread the virus without knowing and you could end up spreading it to someone with underlying health conditions, who are much more likely to die. And that would make you a murderer, morally, although not legally.

Ok, the graphs. First, your risk of dying is low.

Even if you are in the 80+ age category, you only have a 27% chance of needing hospital treatment and a 9% chance of dying. That is much higher than the everyday life of course! This is a serious thing that kills people. A lot of people.

But, for an individual’s risk, you have a 3/4 chance of being able to cope at home, and a 10/11 chance of surviving. Certainly not a Russian roulette game any of us would want to play. But it is good to know that our grandparents having a fighting chance.

Below, is the same graph but zoomed in. The X-axis only runs to 30%. This is not representative of your overall chances but means we can see it better.

In the lower age categories, the outcome looks rosy. If you are in your 30s, for example, you have a 3% chance of requiring hospitalisation and a one in a thousand chance of dying.

I don’t know what percentage of the population have underlying health conditions. But I imagine it increases with age and maybe around 3% for someone in their 30s and may well be 9% for someone in their 80s. If so, that would mean that COVID-19 typically only kills when you have underlying conditions. But I don’t have those figures, I’m speculating. The WHO has stressed that younger people are not invulnerable and they are literally the World Health Organisation, so we should listen to them.

It also seems likely that the stats for underlying health conditions are much higher than those percentages and that most people with underlying conditions are also fine. Or as fine as you can be when you have a nasty flu. As Chris Whitty keeps reminding us, the vast majority of people, even in “at-risk” categories, will get over it.

That’s all for today. See you tomorrow to talk about Black Tuesday :(.

The WHO has now released today’s situation report. Here are some of the headlines:

• China and South Korea are still seeing deaths, but not many.
• Italy recorded 649 deaths, compared to 795 yesterday. It has dropped before and then continued to rise, though.
• The US has reported 201 deaths today, doubling their total. As none were reported yesterday, could just be delayed figures?

Let’s update the graphs.

Deaths per day

Let’s hope today’s result is a sign that Italy is turning the tide and not just an anomaly. On the other hand, let’s hope the US result is an anomaly based on delayed data and goes back to normal tomorrow.

My previous graph showed the incorrect figure for the UK yesterday, which I have now corrected in this graph.

Cumulative deaths

Nothing terribly important to report here, I think. Italy and Spain are still on scary trajectories. It’s too early to say what is going on in the UK. We might follow China. But it is important to remember that Italy weas behind China until day 15. We’re only on day 10, so there is plenty of time for it to accelerate on Italy’s path.

Massively simplistic rules of thumb are a bad idea. But let’s make some anyway. It’s unlikely to start magically dropping at this point (see below), so anything below or around 331 cumulative tomorrow would be a good result. Anything significantly above that would be a bad result. And anything around the 381 mark would be a terrible result.

Social distancing has a delayed effect

One final thought: there is probably at least a 14-day delay between implementing social distancing and seeing any benefit. The virus has an incubation period, then five days of fever and coughing, then the respiratory issues kick in.

We implemented our first set of social distancing (telling people to work from home and not gather in groups) on Tuesday 15 March. That’s six days ago.

We implemented our second set, closing schools and telling people “seriously, stay away from each other” on Saturday 21 March. That was two days ago.

That means that we have 8-12 days of nobody was social distancing damage before we even get to the “we told you all to distance, not cough on each other in the royal parks” damage, which may or may not be resolved. What you do today affects what happens in the ICU two weeks from now.

I’ve been running some numbers based on the situation reports provided by the World Health Organisation. It is not a fun read. But the situation should improve once the first shipment of thoughts and prayers arrive in Europe.

I’m happy to take feedback on these. I’m not a statistician (although there is a lot of stats in psychology), and if you are one and think my graphs are terrible and misleading, I’m open to being corrected.

Deaths per day

China has the most deaths because they have been dealing with this for a long time. People have been dying for 7 weeks now. But not many people and their levels have been going down. The deaths per day in Italy and Spain is far out-racing anything than China saw.

To clarify, this is not cumulative. Even a flat line represents a lot of people dying. A line going up suggests the problem is getting a lot worse.

China still has a problem

This shows the number of deaths per day in China over the past two weeks.

The media are reporting that life in China is going back to normal and that any remaining cases are from people arriving in China. It is true that life is starting to return to normal and people are going outside again. Emergency hospitals have closed and travel restrictions have gone.

However, people are also still dying and the World Health Organisation still reports local transmission.

How far in are we?

This shows the cumulative number of deaths since the 10th death. I followed the Financial Times’s lead on adjusting it this way as, for example, France had one death very early on and then none for a long time. Once you reach the tenth death, you get a far more accurate picture to compare against. Unlike the FT graph, it is not logarithmic. Their graph is just better, to be honest.

At this stage, it is pretty difficult to predict what the UK curve is going to do. We’re only on day 9, compared to day 26 for Italy, day 14 for Spain and day 60 for China.

I’m a psychologist rather than a counsellor. However, I thought my work with Anxiety Leeds and Leeds Anxiety Clinic, and my life, in general, would benefit from a deeper exploration of the theories around talking therapy and person-centred. So, I enrolled on a course with Leeds City College.

Studying has been fun. In terms of academic theory, the textbooks I have been reading have gone deeper than the course does. However, getting to do the interactive practise sessions to allow us to apply the theory have been invaluable. It already feels like it has been translating into better delivery at our group sessions.

And, I’m now formally qualified as a Level 2 Counsellor, which is nice.

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The idea that being overweight is bad for you is well established. Being overweight takes years off your life, so it’s important to eat right and exercise to keep your weight under control. More recent evidence, however, has challenged this.

For example, a 2013 paper in the Journal of the American Medical Association found that overweight people had a lower level of all-cause mortality than people of a healthy weight. The paper was not well-received, but nobody seems to have been able to poke any holes in it, either.

Similarly, a 2009 systematic review published in Deutsches Ärzteblatt International concluded that:

The prevailing notion that overweight increases morbidity and mortality, as compared to so-called normal weight, is in need of further specification.

So, should we give up with the diets and let our waistlines expand a little? Maybe. But even if more evidence goes on to support these findings, there are some good reasons for sticking with the current line on what a healthy BMI is.

Overweight vs obese

Something that all the studies agree on is that people have worse health outcomes, including death, if they are obese. Overweight is one thing, but being obese is bad for you in any study.

And you might be surprised how easy it is to reach the category of obese. Consider that my BMI hovers around 24. 25 is the line between healthy weight and overweight. So, I’m nearly in the overweight category. And I look like this:

Not the buffest individual, that’s for sure, but I don’t look like I’m carrying around any extra weight either. And you only have to move up to a BMI of 30 to go into the obese category.

All-cause morality

As the NHS points out, these studies typically look at all-cause mortality, which means people dying of anything. The problem is that this contradicts individual studies of any topic. For example, if we look at heart disease or diabetes. Whenever we look at the individual causes, we find it is better to be a healthy weight.

There is a huge amount of evidence to support this, so in order for us to accept an alternative view, it would ideally need to explain this discrepancy.

Quality of life

The second problem is that these studies just look at mortality. But that is never the way that NICE or Public Health England have looked at how to provide the most efficient healthcare system.

We measure outcomes in quality-adjusted life-years (QALYs). It’s not enough just to be alive. Modern medicine allows us to keep pretty much anybody alive indefinitely. But sitting in a medically induced coma on a ventilator isn’t a life that any of us would choose.

As a study in Nature points out, being overweight is associated with fewer years of disease-free life. In short, you might experience a longer life, but it won’t be a happier or more fulfilling one.

Indeed, this could help explain the findings. If people are already inside the medical system because they’re having to be treated for obesity-related illnesses, we may be better at spotting other diseases. Or it may be that carrying around some extra weight will reduce your quality of life but also help you to stick around for an extra week when you become seriously ill because you have larger fat reserves.

Conclusion

There is genuine evidence that you will live longer if you are a little overweight (but not obese). However, so far we have been unable to explain why this is. And, more importantly, you will also have a reduced quality of life. Therefore, the current guidelines on maintaining a healthy BMI are still relevant.