Understanding global diversity in the impact of COVID-19


Having written quite extensively about the dire responses of the British government to the crises surrounding COVID-19 earlier in the year, I have held back from further criticism and writing about this for almost two months. It seems extraordinary, though, how few lessons seem to have been learnt in Europe from our experiences with COVID-19 so far, and how so many people seem to be surprised at its recent resurgence. As many of us have said for a long time, this was only to be expected, and is a direct result of the the behaviour both of individuals and also of governments. Above all, it seems to to reflect the selfish individualism, rather than communal responsibility, that has come to dominate many societies in Europe and North America in the 21st century.

The lack of research as to exactly why different countries have such varying mortality rates is also shocking (see my The influence of environmental factors on COVID-19 written in May). As a global community, very much more attention should have been given to this, so that we could by now have a better understanding of what has worked, and what has failed. Answers to these questions would enable governments now to be implementing better policies across the world to mitigate the COVID-19 related deaths that are becoming ever more numerous.

The chart below indicates the very differing numbers of deaths from COVID-19 per 100,000 population in the countries of the world that have had more than 5,000 deaths as of 21st September 2020 (data from https://coronavirus.thebaselab.com). While all such data are notoriously problematic, reported deaths from COVID-19 are more reliable than are data for case numbers (see my Data and the scandal of the UK’s COVID-19 survival rate written in April). Deaths above the usual average (excess mortality) are probably an even better measure, but are unfortunately much more difficult to obtain at a global scale. Furthermore, it must be emphasised that this sample does not include all those countries that have had far fewer deaths, and that much more research is needed in explaining why it is indeed these 25 countries that have had the most deaths in the first place.

This chart raises many unanswered questions, but does at least show two key things:

  • Some countries have “performed” very much “better” and others much “worse” than average. India, Indonesia, Germany and Pakistan appear to have performed significantly better than Peru and Belgium. Why is it, for example, that Peru has 30 times more deaths per 100,000 than does Pakistan? Yet it is extremely difficult to see what either of these groups of countries might have internally in common.
  • There nevertheless seems to be a broad group of very different countries including Sweden, Spain, the UK, Brazil, Chile, Ecuador and the USA that have so far had between 50 and 70 deaths per 100,000. Again, these countries are very diverse, be it in terms of size, demographic structure, political views, or government policies towards COVID-19, although most seem to be fairly right wing and individualistic. Interestingly Sweden with its much more relaxed policy towards social restrictions during COVID-19 appears to have done neither better nor worse than other countries in this group.

The challenge, of course, is to try to understand or explain these patterns but sadly too little research has been done on this in a systematic way to be able to draw any sound conclusions. Put simply, we do not yet really know why countries have had such diverse fortunes. Nevertheless, it is possible to begin to draw some tentative conclusions:

  • Much has been made of the environmental factors possibly influencing the spread of COVID-19, but very little actual process-based research has satisfactorily shown how viable SARS-CoV-2 actually is under a wide range of environmental conditions (see my The influence of environmental factors on Covid-19: towards a research agenda from May). The data above serves as a cautionary warning: countries with similar broad environments tend to have very differing COVID-19 trajectories. Why, for example, are Latin American countries suffering much worse than those of Africa and Asia, although they share many environmental characteritsics in common?
  • A second challenging conclusion is that the actual policies followed by governments may not be that significant in influencing the spread of COVID-19. It is thus striking that Sweden, which has followed very different policies from its neighbours, has not done significantly better or worse than them or indeed other countries such as the UK and the USA, which are widely seen to have failed in dealing with COVID-19.
  • In searching for explanations, it is also pertinent to see whether these rates could in any way be related to varying levels of inequality. However, using the Gini coefficient as a measure of inequality there seems to be no significant relationship with mortality rates (R2 = 0.027).
  • Religious beliefs and practices, likewise, do not seem to be particularly good at explaining these differenceces, although nominally Christian (or atheist) countries do fill the top 15 places in terms of mortality rates, before Iran in 16th place. Other countries with large percentages of Muslims, including Turkey, Egypt, Indonesia and Pakistan all have less than 10 deaths per 100,000. The difference between India and Pakistan (neighbours in South Asia) is particularly interesting, in that India (predominatly Hindu) has a mortality rate more than double that of Pakistan. No satisfactory explanation for this has yet been identified.
  • There has also been some speculation that individualistic societies, where people care more about themselves than they do about being responsible for their neighbours, are having higher mortality rates than do more communal societies, and in this respect the contrasts between the USA and China are indeed very marked. It is extremelt difficult to measure individualism but correlations between the Geert Hofstede Individualism (IDV) Index and mortality rates do not have a strong correlation (R2 = 0.048).

No single explanation would simply account for all of these differences. An important conclusion must therefore be that there is indeed not a single solution (apart from a vaccine or other medical interventions) that is likely to prevent dramatic increases in the prevalance of COVID-19 in these countries, and that many more deaths are therefore certain over the next six months. As individuals, we all know what can make a difference: avoid large groups, wear masks, stay outside as much as possible, wash our hands regularly, and above all act responsibility with respect to others. At all times we mut act as if we have COVID-19, and imagine how we would feel if we were the other people with whom we were interacting, and they knew that we had COVID-19. If there is any solution to COVID-19, it must be that we act responsibly rather than selfishly (see my A differentiated, responsibilities-based approach to living with the Covid-19 pandemic written in June).


The full list of countries with >5000 deaths by 21st September and therefore included in this analysis is (in descending order of deaths per 100,000) : Peru, Belgium, Spain, Brazil, Chile, Ecuador, USA, UK, Italy, Sweden, Mexico, France, Colombia, Netherlands, Argentina, Iran, South Africa, Canada, Russia, Germany, Turkey, India, Egypt, Indonesia, Pakistan

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Where are you willing to take the COVID-19 risk?


I have been exploring the ways through which a sample of countries (mainly the largest ones, European countries, and a smattering of others in Africa, Asia and Latin America) have fared through the COVID-19 pandemic, regularly plotting various correlations beteween different variables.  The challenge, of course, is that the data are hugely unreliable, and reflect different definitions, different cultural practices, different abilities to test, and different political interests (amongst many other factors).  For long, I have argued that data on deaths (including those over and above the norm) are more reliable than those on reported cases, and also that we should not use absolute figures, but rather ratios or percentages (such as deaths per 1 million people).

However, exploring ideas about risk today, I have discovered some fascinating insights.  The Table below indicates the number of new cases reported per 100,000 total population on 24th July in the sample of countries I have been examining (based on data from thebaselab):Screenshot 2020-07-25 at 15.53.47In essence, let’s assume that if you are prepared to go out and about (perhaps even without a mask) in a country that had 1 new reported case per 100,000 yesterday, then you would feel happy with doing so in any country scoring below 1 in the Table.  If you were happy to double the risk, this would include all countries below 2, and so on.  Put another way, the risk in Brazil is about 41 times that in Germany; that in the USA is 21 times as high as in the UK.  This emphasises once again the critical importance of not using absolute numbers, but rather focusing on ratios.  Although I have written extensively about the appalling way in which the UK government has handled COVID-19, and I remain certain that Johnson and Cummings, as well as others close to them, are responsible for many more deaths than might reasonably have been expected, this figure for the UK is actually quite reassuring.

The challenge, of course, is that it is very difficult to interpret these figures because of the uncertainties associated with reported cases – and the data are only for a single dMaskeday.  Many more people will have COVID-19 without it being reported, and it seems clear that asymptomatic carriers can also infect people.  Nevertheless, for those going on holiday in Europe this summer, it would appear that the risk of going to Italy is about one-twelfth that of going to Spain at the moment.

What risk level are you going to be happy with?  And, wherever you go it is surely wise to wear a mask to protect others in case you are an asymptomatic carrier.  Stay well!

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A differentiated, responsibilities-based approach to living with the Covid-19 pandemic


Rosa Graham Thomas - in UK lockdown

Rosa Graham Thomas – in UK lockdown

The United Kingdom has among the worst COVID-19 infection and death rates in the world (see Financial Times, 28th May 2020).  This is in part because of very serious errors of judgement made by the UK Government (see my list of questions to which they must answer, 27th April 2020), but it is also a result of the behaviour of substantial numbers of UK citizens during “lockdown” who, for whatever, chose not to self-isolate  (including the Prime Minister’s Senior Advisor, Dominic Cummings).  The UK government at the end of May also made another serious error of judgement, relaxing the restrictions, even for those who had previously been told to shield themselves, when  daily numbers of new infections and deaths were very much higher than they were when other countries had begun to “open up” (BBC, 31st May 2020).  This is despite the advice of many senior scientists who said that it was too early to relax the restrictions (BBC, 30th May 2020).  Estimates by the Office for National Statistics (28th May 2020) suggested that there were then at least 8000 new cases a day in England, excluding those in care homes or hospitals.  The daily average number of deaths from COVID-19 in the UK to the week ending 31st May was 242 (gov.uk, 31st May 2020).

Countries cannot stay locked down for ever, though, and it is essential for people to go back to work; indeed, it may well be that a vaccine or cure for COVID-19 will not be found in the short term, and societies may have to learn to live with this coronavirus for the foreseeable future.  Difficult decisions will therefore need to be made about how to manage daily life and reduce the number of deaths caused by SARS-Cov-2.  These decisions will need to vary depending on the specific contexts of each country, including its demographics (see my post of 7th May 2020) and environmental factors (see my post of 3rd May 2020).  In the UK, the government has used fairly crude measures, trying to ensure that large numbers of people stayed at home (even though most of them would not be seriously ill if they caught COVID-19), rather than varying the strategy according to risk.  Most actions and discussions have also adopted a human rights based approach to considering how decisions should be made (see for example Morley et al.’s paper on the ethics of tracing apps, or Lord Sumpton’s discussion of why lockdown is despotic).  Instead, I suggest here that we need to adopt highly differentiated strategies, based on our responsibilities (or obligations, as Onora O’Neill suggests in her 2016 book Justice Across Boundaries).

Differentiated risks of COVID-19

There is increasingly sophisticated analysis in various parts of the world to suggest that different groups of people have substantially different risk factors.  While anyone can die from COVID-19, the following generalisations about who is most likely to die seem to have widespread support:

  • Older people are more at risk of having serious complications or dying from COVID-19.  Public Health England (PHE) in their early June 2020 report on disparities in the risk and outcomes of COVID-19, showed that “Among people with a positive test, when compared with those under 40, those who were 80 or older were seventy times more likely to die”.   Dowd et al. (2020) likewise show that “Currently, COVID-19 mortality risk is highly concentrated at older ages, particularly those aged 80+”.  Case Fatality Rates (CFRs) generally increase significantly with age, especially for those over 60; in Italy 96.9% of deaths by the end of March were for those over 60 (Istituto Superiore di Sanità, 2020).  In South Africa 80% of the COVID-19 deaths reported by 2nd May were for people over 50, with a quarter of deaths being in the 60-69 age group.  There is, though, still uncertainty as to whether there is something specific about age itself, or whether these figures are because older people are more likely to have other comorbidities.  It is also interesting to note that the UK’s Office of National Statistics (ONS) Infection Survey pilot suggested that the highest percentage of those testing positive in the UK between 26th April and 24th May were in the 20-49 year age group.
  • Men are more vulnerable than women.  This may well be because women have two X chromosomes (The Guardian, 7th June 2020), although there remains some dispute about the influence of gender on infection and mortality.  The PHE report cited above shows that in England “Working age males diagnosed with COVID-19 were twice as likely to die as females”.  Most surveys seem to suggest that men are more at risk than women, but the ONS survey of those testing positive interestingly indicated that “there is no evidence of differences in the proportions of men or women testing positive for COVID-19”.
  • People with comorbidities are much more likely to be seriously ill or die from COVID-19 than are those who are otherwise healthy.  Data for March reported by the US CDC indicates that almost 90% of all patients hospitalised that month had one or more underlying conditions, with 49.7% having hypertension, 48.3% being obese, 34.6% having chronic lung disease,  28.3% having Type 2 diabetes, and 27.8% having cardiovascular disease.  These five health problems are associated with higher death rates in most places where the data have been studied, although precise percentages vary quite considerably between populations (for a review of underlying metabolic health see Lancet, 2020; for a useful South African perspective, see Cullinan, 2020).  The UK authorities have defined clinically vulnerable people as follows:
    • “aged 70 or older (regardless of medical conditions)
    • under 70 with an underlying health condition listed below (that is, anyone instructed to get a flu jab as an adult each year on medical grounds):
      • chronic (long-term) mild to moderate respiratory diseases, such asasthma,chronic obstructive pulmonary disease (COPD), emphysema orbronchitis○chronic heart disease, such asheart failure
      • chronic kidney disease
      • chronic liver disease, such ashepatitis○chronic neurological conditions, such asParkinson’s disease,motor neurone disease,multiple sclerosis (MS), or cerebral palsy
      • diabetes
      • a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets
      • being seriously overweight (a body mass index (BMI) of 40 or above)
      • pregnant women
    • As above, there is a further category of people with serious underlying health conditions who are clinically extremely vulnerable, meaning they are at very high risk of severe illness from coronavirus”
  • Ethnicity does appear to have an effect on the seriousness of health impacts of COVID-19, even taking other factors into consideration, but the precise reasons for this are not yet known.  In the UK, more people from Black, Asian and Minority Ethnic (BAME) backgrounds have been seriously ill or died from COVID-19 than have people of white ethnicity, but this could be partly explained by deprivation, cultural factors (such as religious and family interactions), and comorbidities (such as obesity, hypertension and diabetes).  England’s PHE report concludes that “An analysis of survival among confirmed COVID-19 cases and using more detailed ethnic groups, shows that after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British”.  More recently, the ISARIC CCP-UK study has shown convincingly that: (i) “Ethnic Minorities in hospital with COVID-19 were more likely to be admitted to critical care and receive IMV than Whites”, and (ii) “South Asians are at greater risk of dying, due at least in part to a higher prevalence of pre-existing diabetes” (see Harrison and Docherty, 17th June 2020).  Insufficient detailed studies have yet been undertaken in other parts of the world, particularly in Africa and Asia, to see whether ethnicity is indeed also a risk factor there.
  • The risk of being infected is higher indoors than out of doors.  This is mainly because there is generally more air movement to disperse SARS-Cov-2 outdoors (although air conditioning systems indoors do spread it in the direction blown by a fan), and people are usually in closer juxtaposition for longer indoors than outside.  It is also easier to maintain sufficient distance between people outdoors than indoors (see inews, 11th May 2020).  However, there is still some uncertainty about this.  Thus, the UK ONS survey claimed in late May 2020 that “Individuals working outside the home show higher rates of positive tests than those who work from home”.  This is, though, probably because those self-isolating and working at home simply don’t come into as much contact with potentially infectious people outside the home.

Much of the research on which these conclusions are drawn is based on early evidence from China, as well as more recent evidence from Europe and the USA where the infection and death rates have been so high.  A particularly interesting issue is therefore whether these generalisations may also apply in other parts of the world, and especially in countries in Africa and South Asia which have yet to experience very serious rates of infection (see my previous post on On ageing populations, “development” and Covid-19).  It may well be that their governments could learn from the mistakes made in the UK and the USA and develop a more nuanced approach as outlined below.

A differentiated risk- and responsibilities-based approach to managing COVID-19

This post makes two core suggestions: states need to adopt nuanced and differentiated responses to living with COVID-19 in the foreseeable future, and that human rights considerations should be balanced by a responsibilities agenda.

A differentiated risk-based approach to COVID-19

Most governments have adopted stringent lockdown policies in response to COVID-19 that have been applied to everyone, regardless of their health risks.  This has caused considerable damage to their economies, as well as other serious health issues.  Many deaths resulting from the existence of COVID-19 are thus not actually being caused by the SARS-COV-2 coronavirus.  Numerous businesses are failing, and fit elderly people have complained vociferously about not being permitted to partake fully in “normal” society.

Now that more is known about the health risks of COVID-19, it makes considerable sense to develop context specific solutions that take into accont the risk factors noted above.  Governments must first ensure that they have an adequate and robust health service capable of dealing with the number of people who are likely to get infected, but wasteful fiascos such as the construction of new Nightingale Hospitals in the UK that were never really needed, or the numerous projects across the world to create novel designs for new venitlators for which not enough nursing staff are available (and when many people on ventilators actually die), must not be repeated.  The hospital services in some countries will come near to being overwhelmed (as in Italy), or may indeed collapse (see recent reports from Brazil, India and Pakistan which seem near this point).  However, even where countries are unable to manage the health requirements of the majority of people affected, it is still vital that what services are available are used to treat those most in need and most likely to survive treatment.  Is is also crucial that a responsibilities approach is inculcated and adopted at all scales from the state to the individual if the impact of the pandemic is to be mitigated.

It would thus seem wise to introduce comprehensive risk-based schemes through which everyone can evaluate their likelihood of being seriously ill from COVID-19 and their risk of infecting other vulnerable people, so that they can take appropriate actions to reduce such risk.  At present, and as noted above, the key risk factors seem to be:

  • age,
  • gender,
  • comorbidities,
  • ethnicity, and
  • location

Put simply, and based largely on European and North American evidence, elderly men with comorbidities from BAME backgrounds spending all their time indoors would seem to be most at risk, and we should all do what we can to help protect them.  Young, fit, active white women spending most of their time outdoors would seem to be least at risk.

This has implications for work, transport, and social life, and carefully nuanced schemes should be introduced to enable as many people as possible to live the lives that they wish to.  For example, where resources are constrained, working-at-home policies could first be made available to the most at risk, encouraging those least at risk to stay at work, or indeed to return to work as previously.  Tourism, travel and entertainment is much less risky for the fit and young, so they should be allowed to take those risks if they want to, while alternative arrangements are put in place for the most vunerably elderly Bangladeshi men (such as support for online tourism or special take-away meals for celebratory occasions).

Responsibilities- rather than rights-based approaches

For too long, rights-based approaches have dominated global and national policies, and insufficient attention has been paid to the responsibilities that are essential to ensure the extstence of well-functioning societies  (see my Prolegomena on Human Rights and Responsibilities).  All too often when a “right” is claimed, it is uncertain who has the “responsibility” to deliver it.  Many, for example, have commented on the human rights aspects of COVID-19 (see Human Rights Watch, 19th March 2020; Bonavero Institute of Human Rights, 6th May 2020; The Guardian, 29th April 2020) , but rather fewer on the human responsibilities dimension.

This is particularly reflected in the tension between individual privacy rights and communal responsibilities in terms of the imposition and use of tracking apps to identify COVID-19 contacts (Human Rights Watch, 13th May 2020; Privacy International, no date; Morley et al., 2020).  However, it also lies at the heart of discussions about wearing masks: all to often such usage is criticised for not really protecting the individual, which completely misses the point that their main use is to protect the community from infected individuals.  People thus have a responsibility to wear masks so that if they are asymptomatic their chances of infecting many others are reduced (see my Face masks and Covid-19: communal not individual relevance).

Two main implications of a shift to a more responsibilities-based approach are important:

  • The first is that governments have a fundamental responsibility to care for their most vulnerable and at risk citizens.  The shocking way in which the UK government placed its focus on “saving the NHS” above “saving vulnerable people” is an all-too-visible example of a failure to adhere to such a principle.  It was a serious injustice for UK policy to have sent elderly people with COVID-19 back into care homes and the community from hospital, as a result of which many of them died, many others were infected, and many more certainly died sooner than they would otherwise have done.  This principle, though, is also of crucial importance in countries where the health services have difficulty, or will have difficulties in the future, in coping with the COVID-19 crisis.  It is absolutely the responsibility of governments to recognise that many low-risk people will survive COVID-19 with little or no lasting health implications, and that they should be allowed to continue if they wish to in the productive economy.  However, at the same time, governments must put in measures whereby those at risk are protected, and given the wherewithall to sustain themselves.
  • The second, and closely related principle is that individuals also have fundamentally important responsibilities to others.  Some positive evidence of communal responsibility and action has been visible in countries across the world during COVID-19, but support for at-risk people has been less than many had hoped for or expected.  Moreover, there have also been substantial numbers of explicitly negative communal actions: digital-attacks on health care organisations have proliferated during the pandemic, and doctors and nurses have been victimised for spreading the coronavirus in countries as diverse as Mexico and Pakistan.  Almost always, the emphasis has been on the rights of the individual (to enjoy the beach or to party) rather than on their responsibilites to others (to protect others from the actions of the self).  Put simply, all of us have responsibilities to protect everyone else from being infected, and to enable as many people as possible to continue to live active and fulfilled lives.

Is it too much to hope for that one of the results of COVID-19 may be the creation of societies where we shift the focus more to our responsibilities towards others than attention on ourselves?  In the short term, this would mean that we should all be:

  • Thinking that we could be asymptomatic carriers of COVID-19, and take actions to prevent us from infecting others;
  • Caring for and serving vulnerable neighbours who cannot benefit from the freedoms that we enjoy; and
  • Taking action to self-isolate and get tested immediately we think we might be infected with COVID-19.

Whilst this is written primarily from the perspective of someone living in a country that is now coming out of lockdown, these principles apply globally, and if adopted in countries that have not yet encountered serious outbreaks of COVID-19 might help them escape some of the more serious impacts of economic shutdown.

Masai children learning in Tanzania

Masai children learning in Tanzania

[Updated 19th June 2020]

 

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On ageing populations, “development” and Covid-19


There is increasingly clear evidence that older people are more likely to die from Covid-19 than are younger people: on 17th February,  the China CDC weekly report showed that among the cases known in China by then, the ≥80 age group had the highest case fatality rate at 14.8% (with the 70-79 age group being 8% and the 60-69% age group being 3.6%); and in early April, the WHO Regional Director for Europe highlighted that over 95% of Covid-19 deaths occurred in those over 60, with more than 50% in those aged 80 years or older.  In the UK, the Office for National Statistics (ONS) reported in mid-April that mortality from Covid-19 increased consistently with age, with only about 13% of deaths being of people under 65.  Significantly, though it noted that men had a death rate double that of women; more recent ONS reports have also shown that (when taking into account age) Black men and women were more than four times as likely to die from Covid-19 then were those of White ethnicity, and that such differences in mortality were partly a result of socio-economic disadvantage.  These data are stark, and are as yet still not fully explained.  As people grow older, they generally have greater comorbidities, and it may be the impact that Covid-19 has on these other health problems that is more significant than age itself.

However, this is an important reminder that Covid-19 is primarily an old-people’s disease.  It is striking to recall that in 1951 life expectancy at birth in England and Wales was only 66.4 for men and 71.5 for women; in 1901 the figures were 48.5 and 52.4 respectively (ONS, 2015).  Put simply, people born 70 years ago were not expected to live to the age at which most people are now dying from Covid-19.  This has important ramifications, and raises very difficult questions.  Have people, perhaps, become over expectant about longevity?  Will Covid-19 temper our aspirations to live for ever?  Will it be a check on the ambitions of companies such as Novartis, Alphabet and Illumina to extend life well beyond 100 years (CNBC, 2019)?  Is the main problem of Covid-19 that most people living in the richer countires of the world have become too cosy in their expectations of living to a ripe old age?

Implications for Europe and north America: too many old people

Thought experiments can be a helpful means of highlighting challenging issues.  Suppose, for example, that there had been no lockdowns in Europe and North America.  It seems very likely that substantial numbers of elderly people would have died already (see projections by epidemiologists at Imperial College which suggested that without mitigation strategies Covid-19 would have resulted in 40 milllion deaths globally in 2020).  If a vaccine or cure is not found, then it still seems likely that large numbers of elderly people will indeed die in Europe at an age well short of what they and their families have grown accustomed to expecting.

However, think of the impact that this will have on the economy and health services.  Once large numbers of elderly people have died, national pension bills will fall, the burden on health services will be reduced, the percentage of people within the economically productive age range will increase, and the economic vitality of their countries will be revitalised.  If Covid-19 (or its successors) become an everyday part of life, the economic “burden” of older people will be dramatically reduced.  It is scarcely surprising that rumours  circulated about the intentions of UK government policy in early- to mid-March.  As Martin Shaw noted at the time, it had been credibly reported that the “Government’s strategy was ‘herd immunity, protect the economy and if that means that some pensioners die, too bad’; or as summed up even more succinctly by a senior Tory, ‘Herd immunity and let the old people die’”.  Whilst the government strenuosly denied this, there is a realistic logic to the idea that letting large numbers of old people die would have clear economic benefits, and would avoid the very considerable costs that are accruing as a result of economic shutdown.

I should stress that this is definitely not a scenario that I would want to encourage or endorse, but in the early part of May, the balance of popular opinion (or the influence of the business community and mainstream media in the UK) does seem to be swinging towards a view that the costs of lockdown are too high to continue to protect the elderly, especially in those countries where there have already been very high death rates (as in Belgium, the UK, France, Italy, Spain and the USA).  Yet, the 20th and latest Imperial College Covid-19 report  concludes for Italy that “even a 20% return to pre-lockdown mobility could lead to a resurgence in the number of deaths far greater than experienced in the current wave in several regions”.

Implications for Africa and South Asia: youthful countries

The real purpose of this reflection, though, is to consider the implications of the above arguments for some of the economically poorest countries in the world.  Data about Covid-19 infections and deaths in Africa and Asia are likely to be even less reliable than they are in Europe, and the countries in these continents are in any case much earlier in their encounters with Covid-19 than are those of Europe.  Recent reports, for example, suggest that the real number of deaths related to Covid-19 may be many times the number that are currently reported (see The Guardian‘s recent report on Somalia).  Nevertheless, we do have relatively accurate data about the demographic structures of most countries in the world.  The chart below therefore shows the relationships between current density of Covid-19 deaths and the percentage of population aged ≥65 for a sample of countries.[i]

Screenshot 2020-05-08 at 08.33.35

This graph is striking, but difficut to interpret (and can be misleading), mainly because most countries in Africa and Latin America are only at an early stage in their Covid-19 outbreaks.  We simply do not know how many deaths they are likely to witness, and few models have yet been published that predict the likely outcomes.   However, with the very notable exceptions of Japan, Greece and Germany, it re-emphasises that high percentages of Covid-19 deaths are mainly found in those countries that have more than 15% of their populations aged ≥65.  Even Brazil, where the death rate is currently growing rapidly, is still nowhere near at the level of mortality that has occurred in Europe and the USA.  The quite remarkable achievement of Greece, with only 147 deaths by 7th May, is also highly noteworthy because despite a fragile health service and an elderly population it has managed to achieve something that most other European countries have been unable to do.  Most commentators suggest that this is mainly because it imposed a dramatic lockdown even before the first deaths were recorded.

Most countries of the world have intiated lockdowns, and these are having particularly significant impacts on the poorest and most marginalised who can least afford it. An obvious question therefore arises: if Covid-19 mainly affects the elderly, should countries with young populations (such as most of those of Africa, Asia and Latin America) follow the “older” countries in imposing strict lockdowns that will have damaging effects on their economies and the livelihoods of those who can least afford it?  Put another way, are the mitigating actions of European and North American countries, where more than 15% of their populations are ≥65, relevant to economically poorer countries with less than 10% of their populations in this age group?

It is far from easy to answer this.  Perhaps the very small numbers of people reportedly dying in Africa at present is only because the coronavirus has not yet gained a grip, and any loosening of the mitigating measures would unleash the pandemic at a scale similar to that seen in Europe.  The WHO, for example, has warned  that the Covid-19 pandemic might kill as many as 190,000 people in Africa in the year ahead (Al Jazeera, 8th May), with many more dying subsequently.  This may well be true, but there is at least a chance that the youthful populations of Africa will be better able to deal with Covid-19 than have done the older populations of Europe.  It must, though, be emphasised that many younger people who are infected with Covid-19 do indeed have serious illnesses, and some die.  We also do not yet know the long-term health impacts of this coronavirus.  Moreover, the evidence that socially disadvantaged people are also more likely to die than their more affluent neighbours further suggests that the poorest and most marginalised in these countries may well have higher death rates.

As I have illustrated elsewhere, there is some (but by no means conclusive) evidence that environmental factors may also play a role in limiting the spread of Covid-19.  If the environments of Africa and South Asia are indeed not particularly conducive to the spread of Covid-19, then their youthful populations might not need to endure the very tight lockdowns imposed in many European countries. That having been said, the rapidly increasing number of infections and deaths in Brazil (with 121,600 cases and 8,022 deaths as of 7th May), which has physical environments and climates similar to many parts of western and southern Africa, does not bode well for the future spread of Covid-19 in Africa.

Conclusions

In conclusion, there remains much that is unknown about how Covid-19 spreads and who it affects most damagingly.  The evidence from Japan, Greece and Germany shows that even when countries do have a high percentage of elderly people, it is still possible to contain and limit the spread of Covid-19, thereby preventing very large numbers of deaths.  The abject failures of governments in countries such as the UK and Belgium to manage the pandemic and save lives likewise indicate how not to respond to the pandemic.  The governments of African and South Asian countries, with their youthful populations who appear less likely to suffer severe symptoms, may well therefore have an advantage over their European counterparts.  If they can draw lessons about what has worked and what has failed, then they are also in a good position to bounce back swiftly from the economic harm caused by economic and social lockdowns.

 


[i] The selected countries included the ten most populous countries in the world (in descending order of total population, China, India, USA, Indonesia, Pakistan, Brazil, Nigeria, Bangladesh, Russia, Mexico), a selection of European countries with mixed trajectories (listed alphabetically, Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, Switzerland), and a diverse sample of African (alphabetically, DRC, Egypt, Kenya, Rwanda, South Africa, Tanzania), and other (alphabetically, Iran, Japan, South Korea, Turkey) countries.

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Filed under Africa, Asia, Covid-19, Environment, Europe, Health

The influence of environmental factors on Covid-19: towards a research agenda


Considerable attention was paid in the early days of the Covid-19 pandemic to its spatial distribution in the hope that environmental factors might be found to play a key role in influencing its spread in two ways: by restricting it to a narrow band of countries with specific environmental factors; and hoping that a rise in temperature in the summer would kill it off.

  • Researchers at Maryland University (Sajadi, M.M. et al., 2020) thus used maps of the early stages of Covid-19 to suggest that it spreads more easily in cold, damp climates, and that its highest incidence would be between latitudes 30-50 N.  At the time, I suggested on 3rd April that there were too many anomalies for this to be valid, that it was only based on limited data (where the coronavirus had spread by early March 2020) and that it was necessary to understand better the actual physical processes involved.  However, the idea that there might be environmental factors that will control Covid-19 still persists.
  • Likewise, in the early days of the pandemic there was much optimism that the new coronavirus might act in similar ways to some of its predecessors and be seasonal in character, waning in the summer months when it gets warmer.  Again, this was in part based on the timing of its outbreak (in China in December 2019 ) and its rapid spread through Europe with an approximately similar timing to seasonal flu.  However, many experts were cautious about this possible scenario (see Jon Cohen in Science, 13th March 2020, and Alvin Powell in the Harvard Gazette, 14th April 2020).

Nevertheless, the much more rapid spread of Covid-19 in Europe and North America than in Africa and South Asia has led some to continue to argue that the devastating impact of lockdown in countries nearer the equator, particularly on the lives of some of the poorest people living there, may be un-necessary if this pattern can indeed be explained by environmental factors.  The lockdown has already been partially rolled back, for example, in countries such as Pakistan (with some factories reopening on 12th April , and congregational prayers at mosques durong Ramadan being permitted from 21st April) and South Africa (with initial steps being taken to reopen the economy on 1st May).  Clearly, the rate and distribution of the spread of Covid-19 is influenced by many factors, including government policies (with the UK performing especially badly, see my recent post),  demographic characteristics (with the elderly being particularly vulnerable), population distribution (spreading slower in sparsely settled areas), characteristics of the several strains and mutations of the Sars-Cov-2 coronavirus (summary in EMCrit), and the inaccuracy and unreliability of reported data about infections and deaths (see my comments here).

The role of environmental factors remains uncertain, despite a considerable amount of research (see systematic review by Mecenas, P. et al., 2020 – thanks to Serge Stinckwich for sharing this) which has sought to draw conclusions from the distribution of cases in parts of the world with different climates, and has suggested that cold and dry conditions helped the spread of the virus whereas warm and wet climates seem to reduce its spread.  A more recent study by Jüni et al. (8th May 2020) has claimed that epidemic growth has little or no association with latitude and temperature, although it has weak negative associations with relative and absolute humidity.  Unfortunately, very few studies have yet sought to do experimental research that actually measures the survivability and ease of spread of Sars-Cov-2 under different real-world environmental conditions.  Moreover, if as appears likely, most infections actually occur indoors, it is not the external climatic conditions that will influence rates of infection but rather the artifical environments created indoors through heating and ventlaltion systems that will be of most significance in influencing its spread.

Two related approaches to this challenge are necessary: identifying its survivabililty in a range of different environments (and surfaces), and analysis of the effect of different environments on the distance that it can be spread by infected people.

Research on the survivability of Sars-Cov-2 in different contexts

Several reported studies have explored the stability of the new coronavirus on different surfaces.  In a widely cited study, van Doremalen et al. (13th  March 2020) suggested that the stability of HCov-19 (Sars-Cov-2) was very similar to that of Sars-Cov-1 (the SARS outbreak in 2003), and that viable virus could be detected as follows:

  • in aerosols up to 3 hours after aerosolization
  • up to 4 hours on copper
  • up to 24 hours on cardboard and up to 47-72 hours on plastic and stainless steel.

This important study has subsequently been used as the standard estimate for the survivability of the coronavirus.  However, it was undertaken in the USA under very specific relatively humidity (for aerosols at 65%; for surfaces at 40%) and temperature conditions (for both at 21-23o C) (See also more recently, van Doremalen et al. 16 April 2020).  A rapid expert review of Sars-Cov-2’s survivability under different conditions (Fineberg, 7th April 2020) notes that the number of experimental studies remains small, but that elevated temperatures seem to reduce its survivability, and that this varies for diffferent materials.  Nevertheless, Fineberg emphasises that laboratory conditions do not necessarily accurately reflect real-world conditions.  In referrring to natural history studies, he also emphasises, as noted above, that conflicting results have emerged because such studies are “hampered by poor quaity data, confounding factors, and insufficient time since the beginning of the pandemix from which to draw conclusions” (p.4).

If a better understanding of Sars-Cov-2’s survivability in different parts of the world is to be gained, it is therefore essential urgently to undertake real world studies of its viability on similar surfaces in various places with different temperature and humidity profiles.

The dispersal distance of Sars-Cov-2

The standard advice across many countries of the world is that people should maintain a minimum distance of 2 m (in some countries 1.5 m) between each other to limit the spread of Covid-19 (see, for example, Public Health England).  This is double the WHO’s advice for the public, which is to “Maintain at least 1 metre (3 feet) distance between yourself and others. Why? When someone coughs, sneezes, or speaks they spray small liquid droplets from their nose or mouth which may contain virus. If you are too close, you can breathe in the droplets, including the COVID-19 virus if the person has the disease“.  The 2 m figure was adopted early by some CDCs, and appears to be more of an approximate early guess (based on the previous Sars-Cov-1 outbreak) that has taken root, rather than an accurate scientifically based figure.

Since then, more rigorous research has been undertaken, much of which suggests that 2 m may not be enough. Setti et al. (23rd April) thus note that Sars-Cov-2 has higher aerosol survivability than did its predecessor, and that a growing body of literature supports a view that “it is plausible that small particles containing the virus may diffuse in indoor environments covering distances up to 10 m from the emission sources”.  They also conclude that “The inter-personal distance of 2 m can be reasonably considered as an effective protection only if everybody wears face masks in daily life activities”. A particularly interesting laboratory based study a month previously by Bourouiba (26th March 2020) provides strong evidence that the turbulent gas clouds formed by sneezes and coughs provide conditions that enable the coronavirus to survive for much longer at greater distances: “The locally moist and warm atmosphere within the turbulent gas cloud allows the contained droplets to evade evaporation for much longer than occurs with isolated droplets“.  She concludes that the “gas cloud and its payload of pathogen-bearing droplets of all sizes can travel 23 to 27 feet (7-8 m)”.  Furthermore, another study by Blocken et al. (9th April) noted that the 1.5 m – 2 m distance was based on people who were standing still, and that there could be a potential aerodynamic effect for people cycling and running.  For someone running at 14.4 km/hr the social distance in the slipstream might be nearer 10 m.

Such studies have been controversial (for a summary, see Eric Niiler in Wired, 14th April), but they highlight that in practice:

  • the “safe’ distance between people is unknown;
  • there is little strong scientific evidence for the 1 m – 2 m recommendations for social distancing; and
  • this distance is highly likely to vary in different environmental contexts.

Not enough conclusive reseach has yet been undertaken on the extent to which environmental factors, such as humidity, pressure, altitude, wind and temperature actually affect how far Sars-Cov-2 will disperse, and at what infectious dose (see Linda Geddes, NewScientist, 27th March 2020, where viral load is also discussed; see also ECDC, 25th March 2020).  It seems likely, though, that dispersal will indeed vary in different conditions, and thus in different parts of the world.  We just don’t yet know how great such variability is.

The latest systematic review published in The Lancet, and cited in The Guardian (2nd June 2020) sugggests that distance does matter, and that not only is 2 m safer than less than 1 m, but also that face masks can indeed reduce substantuially the risk of infection.

Towards a research agenda

This post has emphasised that we actually know remarkably little with certainty about how Sars-Cov-2 physically survives and disperses in different environmental contexts.  This has hugely important ramifications for the spread of Covid-19 in different parts of the world, and thus the mitigating policies and actions that need to be taken.  If, for example, Covid-19 does not survive in hot humid conditions, and is also dispersed over shorter distances in such circumstances, then it might be possible for governments of countries where such conditions prevail not to have to impose such stringent social distancing requirements as those that have been put in place in Europe.

Urgent experimental research is therefore required in real-world environments on:

  • the survivabililty of Sars-Cov-2 in a range of different physical environments (and surfaces), and
  • the effects of different environments on the distance that it can be spread by infected people.

A standard protocol and methodology for such research should be created that could then be used collaboratively by scientists working in different parts of the world to address these crucial issues.  Contrasting environments that would warrant the earliest such research (given the high number of economically poor countries therein) would include: high altitude savanna (as in the Bogotá savanna, and the much lower montane Savanna of the Angolan scarp), tropical and subtropical savanna (as in parts of Brazil and Kenya), tropical rainforests (as in Indonesia and Brazil), semi-arid and arid landscapes (as in much of northern and south-west Africa, the Arabian peninsula, and parts of South Asia).  It is also very important to undertake such resaerch both in urban and rural areas, and indoors as well as outside.  If scientists can indeed co-operate to provide a swift answer to the questions raised in this post, then it would be possible to provide much more tailored advice to governments concerning the mitigating measures (including the use of masks) that they should be taking to protect the highest number of people while also maintaing essential economic activity.

[Updated 8th May, 12th May, 30th May 2020 and 2nd June]

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Filed under Africa, Asia, Covid-19, Geography, India, Pakistan

Questions the UK government must answer over Covid-19


Downing Street

Downing Street, London

With the UK now accounting for about 10% of global deaths from Covid-10, many of my friends from overseas keep asking me why the UK seems to have suffered so badly from the new coronavirus.  As of 23rd April, we had the fourth highest number of deaths as a ratio of total population of any country in the world (at 28 per 100,000), behind Spain (at 47 per 100,000), Italy (at 42 per 100,000), and France (at 33 per 100,000).  My previous posts on Data and the scandal of the UK’s Covid-19 survival rate (11th April) and Face masks and Covid-19: communal not individual relevance (29th March) go part of the way to explain why this is, but they do not fully take into account the increasing amount of evidence that the government has not sufficiently explained, and I thought it might be helpful (at least for me) to try to pull this together into a straightforward list of the key issues (in broadly chronological order):

  • Why did the government not take action following Exercise Cygnus in 2016, and why has it not made the information about this publicly available?  As I have commented before, this exercise  “was undertaken to simulate the impact of a major flu pandemic in the UK. The full conclusions have never been published, but sufficient evidence is in the public domain to suggest that it showed that the NHS was woefully unprepreard, with there being significant predicted shortages of intensive care beds, necessary equipment, and mortuary space”.  The government has also refused to respond to a freedom of information request about this as recently reported in The Guardian (26th April)
  • Why did the government fail to act on warnings in 2019 that we were unprepared for a pandemic? The Guardian (24th April) has also reported that in a leaked document “Ministers were warned last year the UK must have a robust plan to deal with a pandemic virus and its potentially catastrophic social and economic consequences in a confidential Cabinet Office briefing leaked to the Guardian.  The detailed document warned that even a mild pandemic could cost tens of thousands of lives, and set out the must-have ‘capability requirements’ to mitigate the risks to the country, as well as the potential damage of not doing so”.  A recent investigation by the BBC’s Panorama also shows clearly that the government had not stockpiled sufficient protective equipment despite being warned that it needed to do so.  Apparently “There were no gowns, visors, swabs or body bags in the government’s pandemic stockpile when Covid-19 reached the UK”.
  • Why did the government not heed early warnings in January and February of the need for urgent action?  I am neither an epidemiologist nor a medical doctor, but I was already writing in late January about the outbreak of a new coronavirus in China and its potential to have a severe global impact.  If even I was aware, the government has absolutely no excuse for inaction.
  • To what extent did the government’s focus on Brexit mean that they were distracted from the potential havoc of Covid-19?  The Prime Minister’s overarching attention on Brexit and his determination that Britain’s departure from the EU on 31st January was appropriately celebrated, must have taken up a considerable amount of time, and it seems likely that the government simply did not have the systems in place to be able to consider the potential of a new coronavirus that had emerged in a distant land (see also links to racism below).
  • Why did the UK take so long to implement lockdown measures?   The BBC on 7th April provided graphic illustrations of the dates when different countries across the world began to introduce local and national recommendations and lockdowns, and it is very striking that the UK’s lockdown only announced on 23rd March was among the last in Europe.
  • Why has the government’s rhetoric persistently focused more on protecting the NHS than it has on saving lives? My comments here may be controversial, but I have been very struck by the fact that one of the government’s dominant slogans over the last few weeks has been “Stay at home, protect the NHS, save lives“, often shortened to “protect the NHS and save lives”.  The order is always the same, with protecting the NHS coming before saving lives.  This was overwhelmingly emphasised once again in the Prime Minister’s briefing on 30th April where he reiterated that protecting the NHS had been at the centre of the government’s policies, and he paid scant attention to deaths.  It seems to me that this priority largely reflects the government’s desperate wish to protect itself from criticisms of its previous failures to ensure that the NHS was in a fit place to deal with a pandemic.  The slogan could easily have been “Save lives: stay at home and protect the NHS”.  I just get this persistent feeling that many in government really don’t care much about preventing the most vulnerable from dying (see also next item below).
  • Why does so much reliance appear to be being placed on a few (flawed) Prime Ministerial advisors? Again, this question is controversial, but it does seem that there was a dominant view at senior government levels in the UK at the end of February that protecting the economy was more important than saving the lives of some elderly people who were likely to die soon anyway.  This has been traced back by the Sunday Times (22nd March) to a private engagement at the end of February, when Dominic Cummings (Senior Advisor to the Prime Minister) is claimed to have said words to the effect that “herd immunity, protect the economy and if that means some pensioners die, too bad”.  No. 10 immediately issued a very strong rebuttal, claiming that the Sunday Times article was “highly defamatory”.  Nevertheless, detailed examination of the  government’s actions at that time, and before the  change in policy on 16th March would indeed appear to suggest that in general the government was willing to sacrifice the lives of many elderly people, despite claiming that they were caring for the most vulnerable.  The role of Cummings in attending meetings of SAGE (the Scientific Advisory Group for Emergencies) has also been controversial, with The Guardian (26th April) for example reporting that attendees at these meetings were worried about his participation.  Furthermore, Cummings’ personal connections with one of the data-mining companies (Faculty) working with the UK government on Covid-19 (and mining patient data) has also caused concern and controversy (see for example Byline Times 22nd April, The Guardian 24th April and The Times 1st May).  There is enough murkiness about Cummings’ role, for there to be a transparent enquiry into his influence in shaping the government’s flawed Covid-19 response.
  • Why has the government persisted in saying that most UK citizens should not wear masks?  The government has so far persisted in saying that people in the UK should not wear masks (of any kind), despite the very considerable evidence that these can indeed help prevent the spread of Covid-19.  I have written at length about this before, but it seems fairly clear that the reason why the govenrment has done this is because it is afraid that the NHS will not have enough supplies if people try to buy medical face masks for themselves.  Again, this comes back to the issue that Ministers do not want to be shown up for their failure to prepare for the pandemic sufficiently rigorously.  While it seems likely that the government may well soon recommend the use of scarves or homemade cloth coverings as part of its package of actions following the lockdown (The Financial Times, 23rd April), this only further exacerbates their failure to have done so before!
  • Why has the government been so slow to support vulnerable people being supported at home and in care homes? The lack of provision of Personal Protective Equipment (PPE) and other support for staff in care homes, and helping to support elderly people in their own homes has been shocking.    This seems primarily to have been driven by two agendas: the focus on preserving the NHS at all costs for the government’s own political protection; and a willingness to let the vunerable elderly die.   The net outcome has been that very many people have died, both directly and indirectly from Covid-29 in care homes.  In the week ending 10th April there were more deaths (from all causes) in care homes (4,927) and at home (4,117) combined than there were in hospitals (8,578); 1,156 of these deaths in care homes and at home were Covid-19 related (The Health Foundation, 22 April).  More recent figures on 27th April indicated that the number of Covid-19-related deaths  in care homes in the previous week had doubled to more than 2000, meaning that around 3000 Covid-19-related deaths in total have occurred so far in care homes (BBC, 28th April).  The government in its regular briefings, though, only reports deaths from Covid-19 in hospitals, which in the short-term significantly reduces the perceived overall level of deaths from this new coronavirus (for a wider discussion of Covid-19 data, see my Data and the scandal of the UK’s Covid-19 survival rate).  Furthermore, recent evidence from the Chief Scientific Officer indicates clearly that “The risk of the coronavirus spreading in care homes was ‘flagged up very early on’ to the government” (The Times, 28th April).
  • Why have vulnerable people not been directed to hospital sooner: NHS 111 and the need for oxygen? There is much anecdotal evidence that many hospital trusts, at least in the early days of Covid-19 were turning elderly vulnerable people away from hospital, and that NHS 111 (the online and phone service) only told people to go to hospital after being ill with symptoms for more than a week and if they were having severe difficulties breathing.  At the same time, there is good evidence emerging that by the time most people have been taken into hospital in the UK it is probably too late for perhaps half of them to survive. The Independent (9th April) thus reported that over 67% of coronavirus patients put on ventilators go on to die.  It now seems that other forms of treatment may be more effective.  There is a growing  body of evidence that patients are often seriously ill before they begin to have breathing difficulties, and that early oxygenation is key to their survival (New York Times, 20th April 2020).  Hence, if NHS 111 and the government more widely had been willing for Covid-19 patients to go into hospital earlier to increase their oxygen levels before they started having breathing difficulties, many more of them would have been likely to have survived (it is interesting to note also that official NHS guidance on 9th April instructed medical staff to lower oxygen prescribing targets, seemingly to help manage the supplies of oxygen that they had available).  It is shameful that so many beds in the rapidly constructed Nightingale hospitals still remain empty, when they could be used to give patients much needed oxygen.  Indeed, the government announced on 4th May that the London Nightingale hospital would be placed on standby because it was no longer needed (BBC News; see also The Financial Times, reporting on 4th May that the NHS employed 60 KPMG consultants to build these temporary hospitals).
  • Has the government really been acting on the scientific evidence?  Another of the oft-quoted phrases to come out from the government’s media spinners is that they have always been acting on the scientific evidence.  Prime Minister Johnson frequently uses the term, as in “that is why we’re following the scientific evidence in the way that we are” (Bloomberg, 9th March); “Matt Hancock likewise uses the term, as in “The scientific evidence is absolutely critical in underpinning our response” (Financial Times, 15th March).  This is complete and utter nonsense.   There has never been complete uniformity among scientists on anything – and there shouldn’t be; debate and discussion is the lifeblood of healthy science!  Moreover, many academics (see for example Helen Ward in The Guardian, 15th April) have also made it clear that the government has not even acted on the advice given, perhaps in part because of the Cummings’ spin noted above.  Neil Ferguson, leading the team of epidemiologists at Imperial College modelling Covid-19 has recently made two pertinent observations (quoted in The Sunday Times, 26th April): “What I worry about more is people who have a particular political agenda or point of view, distorting the science to support that point of view”; and We have given insight into how different causes of action would lead to certain consequences but we have not made politicians decisions for them. Politicians have made the decisions”.  This is absolutely right.  It is up to governments to make the difficult political decisions, and they cannot hide behind claims that there is something called science which provides all of the definitive answers!
  • Why has the government adopted such an arrogant and racist stance?  In the early stages of the pandemic, far too many people in government, and indeed the British public more generally, conveyed the impression that the new coronavirus was a “Chinese” problem, and that the difficulties faced by the Italians were basically because they were less competent than people in the northern European countries who would easily be able to deal with it.  To be sure this was less blatant than US President Trump’s very clear and explicit racism (The Washington Post, 20th March), but it seems to come from the same stable.  In part this is linked to the ongoing global geopolitical “tensions” between China and “The West” (for my more detailed comments on this see Digital-political-economy in a post-Covid-19 world: implications for the most marginalised),  but it also reflects unwarranted arrogance that the UK’s scientists and systems are better than those in China, other east Asian countries and our southern European neighbours (see, for example, The Sunday Times, 26th April, and The Sunday Times, 26th April).  Perhaps too, this is linked to our government’s mistaken determination to leave the EU with its Mediterranean members, and be “Great” again alone (see The Great Britain Campaign).
  • How and why were the companies selected to work on the data analytics and people tracing technologies associated with Covid-19?  This issue was touched on above with respect to the involvement of Dominic Cummings in the development of digital technology solutions for tracing people with Covid-19 in the UK during and after the lockdown.  I have already discussed the wider and long-term implications of this for the future of privacy and surveillance (see Digital-political-economy in a post-Covid-19 world: implications for the most marginalised), but there are also many questions to be asked about the process which led to companies with at best dubious track records in the field of big data analytics such as Palantir and Faculty (see The Guardian, 12th April, and Byline Times, 27th April) being involved in this development.  The lack of transparency and openness around this by people at the heart of our government is deeply concerning.

These questions raise huge doubts about the judgement and performance of all of the leading figures in our goverment (many of whom have spoken at the daily briefings), as well (sadly) as those senior government advisors who have all too readily towed the goverment’s line in public on these issues, such as Sir Patrick Vallance (Chief Scientific Adviser), Prof. Chris Whitty (Chief Medical Officer) and their deputies.  Whilst it would seem that these advisers have sometimes struggled with following the No. 10 mantra, I do wish that they had been more willing to stand up and be counted for the sake of truth and of UK citizens’ lives.  We must indeed be united as we seek to overcome the challenges posed by Covid-19, but when there is a reckoning afterwards I very much hope that praise is given out where it is due, and failure is also dealt with appropriately.

[This post will be regularly updated as further evidence comes to light]

[Update 29th April: The Guardian today published quite a useful account entitled “Revealed: the inside story of the UK’s Covid-19 crisis” which covers some of the above issues in  more detail]

[Updated 4th May: see The Financial Times report on how the large consultancy firms such as KPMG and Deloitte were contracted by the government without the usual competitive tendering processes to work on projects such as the Nightingale Hospitals]

[Latest update 16.26 4th May 2020]

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Digital-political-economy in a post-Covid-19 world: implications for the most marginalised


Now is the time to be thinking seriously about the kind of world that we wish to live in once Covid-19 has finished its rampage across Europe and North America.[i] Although its potential direct health impact in Africa and South Asia remains uncertain at the time of writing, countries within these continents have already seen dramatic disruption and much hardship as well as numerous deaths having been caused by the measures introduced by governments to restrict its spread.  It is already clear that it is the poorest and most marginalised who suffer most, as witnessed, for example, by the impact of Modi’s lockdown in India on migrant workers.[ii]

This post highlights five likely global impacts that will be hastened by Covid-19, and argues that we need to use this disruption constructively to shape a better world in the future, rather than succumb to the potential and substantial damage that will be caused, especially to the lives of the world’s poorest and most marginalised.  It may be that for many countries in the world, the impact of Covid-19 will be even more significant than was the impact of the 1939-45 war.  Digital technologies are above all accelerators, and most of those leading the world’s major global corporations are already taking full advantage of Covid-19 to increase their reach and their profits.[iii]

The inexorable rise of China and the demise of the USA

http://hiram1555.com/2016/10/21/presidential-debates-indicate-end-of-us-empire-analyst/

Source: Hiram1555.com

I have written previously about the waxing of China and the waning of the USA; China is the global political-economic powerhouse of the present, not just of the future.[iv]  One very significant impact of Covid-19 will be to increase the speed of this major shift in global power.  Just as 1945 saw the beginning of the final end of the British Empire, so 2020 is likely to see the beginning of the end of the USA as the dominant global (imperial) power.  Already, even in influential USAn publications, there is now much more frequent support for the view that the US is a failing state.[v] This transition is likely to be painful, and it will require world leaders of great wisdom to ensure that it is less violent than may well be the case.

The differences between the ways in which the USA and China have responded to Covid-19 have been marked, and have very significant implications for the political, social and economic futures of these states.  Whilst little trust should be placed on the precise accuracy of reported Covid-19 mortality rate figures throughout the world, China has so far reported a loss of 3.2 people per million to the disease (as of 17 April, and thus including the 1290 uplift announced that day), whereas the USA has reported deaths of 8.38 per 100,000 (as of that date); moreover, China’s figures seem to have stabilised, whereas those for the USA continue to increase rapidly.[vi]  These differences are not only very significant in human terms, but they also reflect a fundamental challenge in the relative significance of the individual and the community in US and Chinese society.

Few apart from hardline Republicans in the USA now doubt the failure of the Trump regime politically, socially, economically and culturally. This has been exacerbated by the US government’s failure to manage Covid-19 effectively (even worse than the UK government’s performance), and its insistent antagonism towards China through its deeply problematic trade-war[vii] even before the outbreak of the present coronavirus. Anti-Chinese rhetoric in the USA is but a symptom of the realisation of the country’s fundamental economic and policial weaknesses in the 21st century.   President Trump’s persistent use of the term “Chinese virus” instead of Covid-19[viii] is also just a symptom of a far deeper malaise.   Trump is sadly not the problem; the problem is the people and system that enabled him to come to power and in whose interests he is trying to serve (alongside his own).  China seems likely to come out of the Covid-19 crisis much stronger than will the USA.[ix]

Whether people like it or not, and despite cries from the western bourgeoisie that it is unfair, and that the Chinese have lied about the extent of Covid-19 in their own country in its early stages, this is the reality.  China is the dominant world power today, let alone tomorrow.

An ever more digital world

https://www.forbes.com/sites/columbiabusinessschool/2020/04/21/how-covid-19-will-accelerate-a-digital-therapeutics-revolution/

Source: Forbes.com

The digital technology sector is already the biggest winner from Covid-19.  Everyone with access, knowledge and ability to pay for connectivity and digital devices has turned to digital technologies to continue with their work, maintain social contacts, and find entertainment during the lockdowns that have covered about one-third of the world’s population by mid-April.[x]  Those who previously rarely used such technologies, have overnight been forced to use them for everything from buying food online, to maintaining contacts with relatives and friends.

There is little evidence that the tech sector was prepared for such a windfall in the latter part of 2019,[xi] but major corporations and start-ups alike have all sought to exploit its benefits as quickly as possible in the first few months of 2020, as testified by the plethora of announcements claiming how various technologies can win the fight against Covid-19.[xii]

One particularly problematic outcome has been the way in which digital tech champions and activists have all sought to develop new solutions to combat Covid-19.  While sometimes this is indeed well intended, more often than not it is primarily so that they can benefit from funding that is made available for such activities by governments and donors, or primarily to raise the individual or corporate profile of those involved.  For them, Covid-19 is a wonderful business opportunity.  Sadly, many such initiatives will fail to deliver appropriate solutions, will be implemented after Covid-19 has dissipated, and on some occasions will even do more harm than good.[xiii]

There are many paradoxes and tensions in this dramatically increased role of digital technology after Covid-19. Two are of particular interest.  First, many people who are self-isolating or social distancing are beginning to crave real, physical human contact, and are realising that communicating only over the Internet is insufficiently fulfilling.  This might offer some hope for the future of those who still believe in the importance of non-digitally mediated human interaction, although I suspect that such concerns may only temporarily delay our demise into a world of cyborgs.[xiv] Second, despite the ultimate decline in the US economy and political power noted above, US corporations have been very well placed to benefit from the immediate impact of Covid-19, featuring in prominent initiatives such as UNESCO’s Global Education Coalition,[xv] or the coalition of pharmaceutical companies brought together by the Gates Foundation.[xvi]

Whatever the precise details, it is an absolute certainty that the dominance of digital technologies in everyone’s lives will increase very dramatically following Covid-19 and this will be exploited by those intent on reaping the profits from such expansion in their own interests.

Increasing acceptance of surveillance by states and companies: the end of privacy as we know it.

https://www.wired.com/story/phones-track-spread-covid19-good-idea/

Source: Wired.com

A third, related, global impact of Covid-19 will be widely increased global acceptance of the roles of states and companies in digital surveillance.  Already, before 2020, there was a growing, albeit insufficient, debate about the ethics of digital surveillance by states over issues such as crime and “terrorism”, and its implications for privacy.[xvii]  However, some states, such as China, South Korea, Singapore and Israel, have already used digital technologies and big data analytics extensively and apparently successfully in monitoring and tracking the spread of Covid-19,[xviii] and other coalitions of states and the private sector are planning to encourage citizens to sign up to having fundamental aspects of what has previously been considered to be their private and personal health information made available to unknown others.[xix]

One problem with such technologies is that they require substantial numbers of people to sign up to and then use them.  In more authoritarian states where governments can make such adherence obligatory by imposing severe penalties for failure to do so, they do indeed appear to be able to contribute to reduction in the spread of Covid-19 in the interests of the wider community.  However, in more liberal democratic societies, which place the individual about the community in importance, it seems less likely that they will be acceptable.

Despite such concerns, the growing evidence promoted by the companies that are developing them that such digital technologies can indeed contribute to enhanced public health will serve as an important factor in breaking down public resistance to the use of surveillance technologies and big data analytics.  Once again, this will ultimately serve the interest of those who already have greater political and economic power than it will the interests of the most marginalised.

Online shopping and the redesign of urban centres.

https://www.independent.co.uk/life-style/health-and-families/coronavirus-herd-immunity-meaning-definition-what-vaccine-immune-covid-19-a9397871.html

Source: Independent.co.uk

Self-isolation and social distancing have led to the dramatic emptying of towns and cities across the world.  Businesses that have been unable to adapt to online trading have overnight been pushed into a critical survival situation, with governments in many of the richer countries of the world being “forced” to offer them financial bail-outs to help them weather the storm.  Unfortunately, most of this money is going to be completely wasted and will merely create huge national debts for years into the future.  People who rarely before used online shopping are now doing so because they believe that no other method of purchasing goods is truly safe.

The new reality will be that most people will have become so used to online shopping that they are unlikely to return in the future to traditional shopping outlets. Companies that have been unable to adjust to the new reality will fail.  The character of our inner-city areas will change beyond recognition.  This is a huge opportunity for the re-design of urban areas in creative, safe and innovative ways.  Already, the environmental impact of a reduction in transport and pollution has been widely seen; wildlife is enjoying a bonanza; people are realising that their old working and socialising patterns may not have been as good as they once thought.[xx]  Unfortunately, it is likely that this opportunity may not be fully grasped, and instead governments that lack leadership and vision will instead seek to prop up backward-looking institutions, companies and organisations, intent on preserving infrastructure and economic activities that are unfit for purpose in the post-pandemic world.  Such a mentality will lead to urban decay and ghettoization, where people will fear to tread, and there is a real danger of a downward spiral of urban deprivation.

There are, though, many bright signs of innovation and creativity for those willing to do things differently.  Shops and restaurants that have been able to find efficient trustworthy drivers are now offering new delivery services; students are able to draw on the plethora of online courses now available; new forms of communal activity are flourishing; and most companies are realising that they don’t actually need to spend money on huge office spaces, but can exploit their labour even more effectively by enabling them to work from home.

We must see the changes brought about by responses to Covid-19 as important opportunities to build for the future, and to create human-centred urban places that are also sensitive to the natural environments in which they are located.

Increasing global inequalities

https://gulfnews.com/photos/news/indian-migrants-forced-to-walk-home-amid-covid-19-lockdown-1.1585394226024?slide=2

Source: Gulfnews.com

The net outcome of the above four trends will lead inexorably to a fifth, and deeply concerning issue: the world will become an even more unequal place, where those who can adapt and survive will flourish, but where the most vulnerable and marginalised will become even more immiserated.

This is already all too visible.  Migrant workers are being ostracised, and further marginalised.[xxi]  In India, tens of thousands of labourers are reported to have left the cities, many of them walking home hundreds of kilometres to their villages.[xxii] In China, Africans are reported as being subjected to racist prejudice, being refused service in shops and evicted from their residences.[xxiii]  In the UK, many food banks have had to close and it is reported that about 1.5. million people a day are going without food.[xxiv]  The World Bank is reporting that an extra 40-50 million people across the world will be forced into poverty by Covid-19, especially in Africa.[xxv]  People with disabilities have become even more forgotten and isolated.[xxvi]  The list of immediate crises grows by the day.

More worrying still is that there is no certainty that these short-term impacts will immediately bounce-back once the pandemic has passed.  It seems at least as likely that many of the changes will have become so entrenched that aspects of living under Covid-19 will become the new norm.  Once again, those able to benefit from the changes will flourish, but the uneducated, those with disabilities, the ethnic minorities, people living in isolated areas, refugees, and women in patriarchal societies are all likely to find life much tougher in 2021 and 2022 even than they do at present.   Much of this rising inequality is being caused, as noted above, by the increasing role that digital technologies are playing in people’s lives.  Those who have access and can afford to use the Internet can use it for shopping, employment, entertainment, learning, and indeed most aspects of their lives.  Yet only 59% of the world’s population are active Internet users.[xxvii]

Looking positively to the future.

People will respond in different ways to these likely trends over the next few years, but we will all need to learn to live together in a world where:

  • China is the global political economic power,
  • Our lives will become ever more rapidly experienced and mediated through digital technology,
  • Our traditional views of privacy are replaced by a world of surveillance,
  • Our towns and cities have completely different functions and designs, and
  • There is very much greater inequality in terms of opportunities and life experiences.

In dealing with these changes, it is essential to remain positive; to see Covid-19 as an opportunity to make the world a better place for everyone to live in, rather than just as a threat of further pain, misery and death, or an opportunity for a few to gain unexpected windfall opportunities to become even richer.  Six elements would seem to be important in seeking to ensure that as many people as possible can indeed flourish once the immediate Covid-19 pandemic has dissipated:

  • First, these predictions should encourage all of us to prioritise more on enhancing the lives of the poorest and the most marginalised, than on ensuring economic growth that mainly benefits the rich and privileged. This applies at all scales, from designing national health and education services, to providing local, community level care provision.
  • This requires an increased focus on negotiating communal oriented initiatives and activities rather than letting the greed and selfishness of individualism continue to rule the roost.
  • Third, it is essential that we use this as an opportunity to regain our physical sentient humanity, and reject the aspirations of those who wish to create a world that is only experienced and mediated through digital technology. We need to regain our very real experiences of each other and the world in which we live through our tastes, smells, the sounds we hear, the touches we feel, and the sights we see.
  • Fourth, it seems incredibly important that we create a new global political order safely to manage a world in which China replaces the USA as the dominant global power. The emergence of new political counterbalances, at a regional level as with Europe, South Asia, Africa and Latin America seems to be a very important objective that remains to be realised.  Small states that choose to remain isolated, however arrogant they are about the “Great”ness of their country, will become ever more vulnerable to the vagaries of economic, political and demographic crisis.
  • Fifth, we need to capitalise on the environmental impact of Covid-19 rapidly to shape a world of which we are but a part, and in which we care for and co-operate with the rich diversity of plant and animal life that enjoys the physical richness of our planet. This will require a comprehensive and rigorous evaluation of the harm caused to our world by the design and use of digital technologies.[xxviii]
  • Finally, we need to agree communally on the extent to which individual privacy matters, and whether we are happy to live in a world of omnipresent surveillance by companies (enabling them to reap huge profits from our selves as data) and governments (to maintain their positions of power, authority and dominance). This must not be imposed on us by powerful others.  It is of paramount importance that there is widespread informed public and communal discussion about the future of surveillance in a post-Covid-19 era.

I trust that these comments will serve to provoke and challenge much accepted dogma and practice.  Above all, let’s try to think of others more than we do ourselves, let’s promote the reduction of inequality over increases in economic growth, and let’s enjoy  an integral, real and care-filled engagement with the non-human natural world.


Notes:

[i] For current figures see https://coronavirus.thebaselab.com/ and https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6, although all data related with this coronavirus must be treated with great caution; see https://unwin.wordpress.com/2020/04/11/data-and-the-scandal-of-the-uks-covid-19-survival-rate/

[ii] Modi’s hasty coronavirus lockdown of India leaves many fearful for what comes next, https://time.com/5812394/india-coronavirus-lockdown-modi/

[iii] Jack Dorsey, the founder of Twitter and Square, might well be an exception with his $1 billion donation to support Covid-19 relief and other charities; see https://www.theverge.com/2020/4/7/21212766/jack-dorsey-coronavirus-covid-19-donate-relief-fund-square-twitter

[iv] See, for example, discussion in Unwin, T. (2017) Reclaiming ICT4D, Oxford: Oxford University Press.  I appreciate that such arguments infuriate many people living in the USA,

[v] See, for example, George Parker’s, We Are Living in a Failed State: The coronavirus didn’t break America. It revealed what was already broken, The Atlantic, June 2020 (preview) https://www.theatlantic.com/magazine/archive/2020/06/underlying-conditions/610261/.

[vi] Based on figures from https://coronavirus.thebaselab.com/ on 15th April 2020.  For comparison, Spain had 39.74 reported deaths per 100,000, Italy 35.80, and the UK 18.96.

[vii] There are many commentaries on this, but The Wall Street Journal’s account on 9 February 2020 https://www.wsj.com/articles/u-s-china-trade-war-reshaped-global-commerce-11581244201 is useful, as is the Pietersen Institute’s timeline https://www.piie.com/blogs/trade-investment-policy-watch/trump-trade-war-china-date-guide.

[viii] For a good account of his use of language see Eren Orbey’s comment in The New Yorker, Trump’s “Chinese virus” and what’s at stake in the coronovirus’s name,  https://www.newyorker.com/culture/cultural-comment/whats-at-stake-in-a-viruss-name

[ix] China’s massive long-term strategic investments across the world, not least through its 一带一路 (Belt and Road) initiative, have placed it in an extremely strong position to reap the benefits of its revitalised economy from 2021 onwards (for a good summary of this initiative written in January 2020 see https://www.cfr.org/backgrounder/chinas-massive-belt-and-road-initiative)

[x] Kaplan, J., Frias, L. and McFall-Johnsen, M., A third of the global population is on coronavirus lockdown…, https://www.businessinsider.com/countries-on-lockdown-coronavirus-italy-2020-3?r=DE&IR=T

[xi] This is despite conspiracy theorists arguing that those who were going to gain most from Covid-19 especially in the digital tech and pharmaceutical industry had been active in promoting global fear of the coronavirus, or worse still had actually engineered it for their advantage.  See, for example, The New York Times, https://www.nytimes.com/2020/04/17/technology/bill-gates-virus-conspiracy-theories.html, or Thomas Ricker, Bill Gates is now the leading target for Coronavirus falsehoods, says report, https://www.theverge.com/2020/4/17/21224728/bill-gates-coronavirus-lies-5g-covid-19 .

[xii] See, for example, Shah, H. and Kumar, K., Ten digital technologies helping humans in the fight against Covid-19, Frost and Sullivan, https://ww2.frost.com/frost-perspectives/ten-digital-technologies-helping-humans-in-the-fight-against-covid-19/, Gergios Petropolous, Artificial interlligence in the fight against COVID-19, Bruegel, https://www.bruegel.org/2020/03/artificial-intelligence-in-the-fight-against-covid-19/, or Beech, P., These new gadgets were designed to fight COVID-19, World Economic Forum, https://www.weforum.org/agenda/2020/04/coronavirus-covid19-pandemic-gadgets-innovation-technology/. It is also important to note that the notion of “fighting” the coronavirus is also deeply problematic.

[xiii] For my much more detailed analysis of these issues, see Tim Unwin (26 March 2020), collaboration-and-competition-in-covid-19-response, https://unwin.wordpress.com/2020/03/26/collaboration-and-competition-in-covid-19-response/

[xiv] For more on this see Tim Unwin (2017) Reclaiming ICT4D, Oxford: Oxford University Press, and for a brief comment https://unwin.wordpress.com/2016/08/03/dehumanization-cyborgs-and-the-internet-of-things/.

[xv] Although, significantly, Chinese companies are also involved; see https://en.unesco.org/covid19/educationresponse/globalcoalition

[xvi] For the work of the Gates Foundation and US pharmaceutical companies in fighting Covid-19 https://www.outsourcing-pharma.com/Article/2020/03/27/Bill-Gates-big-pharma-collaborate-on-COVID-19-treatments

[xvii] There is a huge literature, both academic and policy related, on this, but see for example OCHCR (2014) Online mass-surveillance: “Protect right to privacy even when countering terrorism” – UN expert, https://www.ohchr.org/SP/NewsEvents/Pages/DisplayNews.aspx?NewsID=15200&LangID=E; Privacy International, Scrutinising the global counter-terrorism agenda, https://privacyinternational.org/campaigns/scrutinising-global-counter-terrorism-agenda; Simon Hale-Ross (2018) Digital Privacy, Terrorism and Law Enforcement: the UK’s Response to Terrorist Communication, London: Routledge; and Lomas, N. (2020) Mass surveillance for national security does conflict with EU privacy rights, court advisor suggests, TechCrunch, https://techcrunch.com/2020/01/15/mass-surveillance-for-national-security-does-conflict-with-eu-privacy-rights-court-advisor-suggests/.

[xviii] Kharpal, A. (26 March 2020) Use of surveillance to fight coronavirus raised c oncenrs about government power after pandemic ends, CNBC, https://www.cnbc.com/2020/03/27/coronavirus-surveillance-used-by-governments-to-fight-pandemic-privacy-concerns.html; but see also more critical comments about the efficacy of such systems as by Vaughan, A. (17 April 2020) There are many reasons why Covid-19 contact-tracing apps may not work, NewScientist, https://www.newscientist.com/article/2241041-there-are-many-reasons-why-covid-19-contact-tracing-apps-may-not-work/

[xix] There are widely differing views as to the ethics of this.  See, for example, Article 19 (2 April 2020) Coronavirus: states use of digital surveillance technologies to fight pandemic must respect human rights, https://www.article19.org/resources/covid-19-states-use-of-digital-surveillance-technologies-to-fight-pandemic-must-respect-human-rights/ ; McDonald, S. (30 March 2020) The digital response to the outbreak of Covid-19, https://www.cigionline.org/articles/digital-response-outbreak-covid-19. See also useful piece by Arcila (2020) for ICT4Peace on “A human-centric framework to evaluate the risks raised by contact-tracing applications” https://mcusercontent.com/e58ea7be12fb998fa30bac7ac/files/07a9cd66-0689-44ff-8c4f-6251508e1e48/Beatriz_Botero_A_Human_Rights_Centric_Framework_to_Evaluate_the_Security_Risks_Raised_by_Contact_Tracing_Applications_FINAL_BUA_6.pdf.pdf

[xx] See, for example, https://www.bbc.com/future/article/20200326-covid-19-the-impact-of-coronavirus-on-the-environment, https://www.msn.com/en-gb/news/world/the-environmental-impact-of-covid-19/ss-BB11JxGv?li=BBoPWjQ, https://www.theguardian.com/world/2020/mar/26/life-after-coronavirus-pandemic-change-world, and https://www.scientificamerican.com/article/how-the-coronavirus-pandemic-is-affecting-co2-emissions/.

[xxi] See The Guardian (23 April 2020) ‘We’re in a prison’: Singapore’s million migrant workers suffer as Covid-19 surges back, https://www.theguardian.com/world/2020/apr/23/singapore-million-migrant-workers-suffer-as-covid-19-surges-back

[xxii] Al Jazeera (6 April 2020) India: Coronavirus lockdown sees exodus from cities, https://www.aljazeera.com/programmes/newsfeed/2020/04/india-coronavirus-lockdown-sees-exodus-cities-200406104405477.html.

[xxiii] Financial Times (13th April) China-Africa relations rocked by alleged racism over Covid-19, https://www.ft.com/content/48f199b0-9054-4ab6-aaad-a326163c9285

[xxiv] Global Citizen (22 April 2020) Covid-19 Lockdowns are sparking a hunger crisis in the UK, https://www.globalcitizen.org/en/content/covid-19-food-poverty-rising-in-uk/

[xxv] Mahler, D.G., Lakner, C., Aguilar, R.A.C. and Wu, H. (20 April 2020) The impact of Covid-19 (Coronavirus) on global poverty: why Sub-Saharan Africa might be the region hardest hit, World Bank Blogs, https://blogs.worldbank.org/opendata/impact-covid-19-coronavirus-global-poverty-why-sub-saharan-africa-might-be-region-hardest

[xxvi] Bridging the Gap (2020) The impact of Covid-19 on persons with disabilities, https://bridgingthegap-project.eu/the-impact-of-covid-19-on-people-with-disabilities/

[xxvii] Statista (Januarv 2020) https://www.statista.com/statistics/269329/penetration-rate-of-the-internet-by-region/

[xxviii] For a wider discussion of the negative environmental impacts of climate change see https://unwin.wordpress.com/2020/01/16/digital-technologies-and-climate-change/.

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Data and the scandal of the UK’s Covid-19 survival rate


Govt CovidI have held off writing much that is overtly critical of the UK government’s handling of the Covid-19 pandemic, but can do so no longer. We have known for a long time that data published by governments across the world about infections is highly unreliable, although figures on deaths are somewhat more representative of reality.  The UK governments’s lack of transparency, though, about its Covid-19 data is deeply worrying, and suggests deliberate deceipt.  The following observations may be noted about the figures that are currently being published, and the ways in which official (and social) media use them.

  • Official infection rates are very unreliable and largely reflect the number of tests being done.  These figures are so meaningless that they should be ignored in public announcements and media coverage because they give the public completely the wrong impression.  Countries such as Germany are believed to be able to produce up to 500,000 tests a week (although their aim is to do 200,000 tests a day), whereas by 7th April there had only been 218,500 tests in total in the UK since the start of January. The UK government aims to achieve 100,000 tests a day by the end of April, but seems highly unlikely to meet this target; a figure of more than 10,000 tests per day in the UK was only first achieved on 1st April.  The official reported number of infected cases in Germany at 119,624 on 10th April is  likely to be somewhat nearer reality than the paltry 73,758 reported cases in the UK (Source: thebaselab, 10th April).  In practice, it seems that most of the UK figures actually refer to those who are tested in hospital as suspected cases, since there is negligible testing of the public in general to get an idea of how extensive the spread really is.  By keeping this figure apparently low, the UK government seems to be deceiving the population into believing that Covid-19 might be less extensive than in reality it is.
  • Figures for the number of deaths should be more reliable, but are also opaque.  Even with figures for deaths there is increasing cause for doubt, not least because of differences between countries reporting whether someone has died “from” or “with” Covid-19.  In practice, it is even more complex than this, since some countries (such as the UK), are publishing immediate data only on those who die in hospital.  Those who die in the community are only added into the total official figures at a later date.  By manipulating when these figures are officially added, governments can again deceive their citizens that the deaths may in the short-term be lower than they are in reality.  A good analysis of the situation in the UK has recently (8th April) been produced by Jason Oke and Carl Heneghan for The Centre for Evidence-Based Medicine (CEBM), which highlights the considerable discrepancies between data made available by the National Health Service (NHS) and Public Health England (PHE).  Not only does this make it difficult in the short-term for modellers and policy makers to know what is really happening, but it also gives a distorted picture to the public.  As this report also concludes “The media should be wary of reporting daily deaths without understanding the limitations and variations in different sources”.
  • Hugely unreliable mortality rates.  Combining published figures for infections and deaths gives rise to figures for mortality rates.  These figures are also therefore very unreliable.  Because of the low levels of testing, and yet the high number of deaths in the UK (8,958; Source: thebaselab, 10th April), the UK mortality rate is reportedly the second highest in the world at 12.15%.  This can be compared with Germany’s 2.18% (undoubtedly a much more accurate figure), Italy’s 12.77% (the highest in the world), and a global average of 6.06%.  As I have argued previously, though, these figures are largely meaningless, and the figures that really matter are the total number of deaths divided by the total population of a country.  Accordingly, to date, China has had only 0.23 deaths per 100,000 people, whereas Spain has had 33.88, Italy 30.23, France 18.80 and the UK currently 11.75 deaths per 100,000 (Source: derived from thebaselab, 10th April).  Put another way, the UK figure is 51 times more than the Chinese figure.  Such figures are far more meaningful than official mortality rates, and should always be used by the media (preferably using choropleth maps rather than proportional circles for total deaths).
  • Extraordinarily depressing recovery rates.  The UK’s current “recovery rate” is by any standards appalling.  As of 9th April reported figures for the number of people who have recovered from Covid-19 in the UK were between 135 (by the baselab, and worldometers) and 351 (by Johns Hopkins University).   This suggests a “recovery rate” of possibly only 0.18% in the UK (Source:  thebaselab, 10th April), in contrast with China’s 94.56%, Spain’s 35.45% and a global average of 22.2%.  In part this is again a result of data problems.  We simply don’t know how many people have been infected mildly, and how many have survived without even knowing they have had it.  It also reflects the fact that it takes time to recover, and many people are still in hospital who may yet recover.  However, the UK’s figures is the worst in the world for countries where there have been more than 50 cases of Covid-19.

Such figures raise huge questions for the British government and people:

  • Why are UK reported survival rates so low? Surely the government should want to do all it can to show the success of the NHS in treating patients and it should therefore publish the real figures?  That is unless, of course, these figures are truly bad.
  • What is the balance of numbers between those dying in hospital from Covid-19 and those leaving having recovered?  The rare euphoria that greets those who leave hospital having recovered (as with 101-year-old Keith Watson who was recently discharged from a hospital in Worcestershire) suggests that very few people have actually left hospital alive having been admitted with Covid-19.  Is the government trying to hide this?  Is the grim truth that you are likely to die if you go into hospital with Covid-19?  Does this mean that people are being admitted to hospital far too late because of the advice given by the NHS and its 111 service?  Should the NHS simply stop trying to treat patients with Covid-19? (An update noted below suggests that more than half of the people going into intensive care in UK hospitals with Covid-19 die).
  • Why did the government not act sooner?  Some of us had argued back in January of the threat posed by the then un-named new coronavirus (I first raised concerns on 20th January, and first posted about its extent in China on social media on 27th January).  It was very clear then (and not only with hindsight) that this posed a global threat.  Undoubtedly the WHO failed in its warnings, and did not act quickly enough to declare a pandemic, but many governments did act to get in supplies of Personal Protective Equipment (PPE), testing equipment, and ventilators.  The UK government has failed its people.  One quarter of my close family have probably already had Covid-19; many of my friends have also had it – some very seriously.  I guess therefore that between a quarter and a third of those living in the UK may already been ill with the pandemic (Update 13th April: this must be an exaggeration, as news media over Easter suggest that experts think the current figure of infections is only 10%; Update 26th April, the MRC-IDE at Imperial College modelling back from actual deaths, suggest that only some 4.36% of the UK population is infected).  They are individual human beings, and not just statistics.

These questions are hugely important now, and not just when a future review is done, because it is still not too late to act together wisely to try to limit the impact of Covid-19 in the UK.  The fact that the government has not yet been transparent and open about these issues is deeply worrying.  In trying to explain them the following scenarios seem likely.  I very much hope they are not true, and that the government can provide clear evidence that I am wrong:

1. Throughout, the government knew that the NHS would be overwhelmed by Covid-19, and has been doing all it can to cover up its own failings and to protect the NHS.  In 2016, a review called Exercise Cygnus was undertaken to simulate the impact of a major flu pandemic in the UK. The full conclusions have never been published, but sufficient evidence is in the public domain to suggest that it showed that the NHS was woefully unprepreard, with there being significant predicted shortages of intensive care beds, necessary equipment, and mortuary space.  In December 2016 the then excellent Chief Medical Officer Dame Sally Davies, conceded that “a lot of things need improving”.  It is now apparent that the government (largely including people who are still leading it) did nothing to rectify the situation, and must therefore be held in part responsible for the very high death rate in the UK.  Its failure to fund the NHS appropriately in recent years is but a wider symptom of this lack of care and attention to the needs of our health system.  I therefore find it very depressing that this government is now so adamant in asking us to protect the NHS; as shown on the cover of the document sent to all households in the UK (illustrated above), it seems to be more concerned with protecting the NHS (listed second) above saving lives (listed third).

2. The government has consigned those least likely to survive Covid-19 to death in their homes.  Despite claims that the government is caring for the most vulnerable, it seems probable that its advice to the elderly and those most at risk to stay at home was not intended primarily for their own good, but was rather to prevent the NHS from being flooded with people who were likely to die.  This is callous, calculating and contemptable.  On March 22nd, The Sunday Times published an article that stated that “At a private engagement at the end of February, Cummings [the Prime Minister’s Chief Advisor] outlined the government’s strategy. Those present say it was “herd immunity, protect the economy and if that means some pensioners die, too bad”. Downing Street swiftly denounced this report, but it remains widely accepted that even if these were not the exact words Cummings used, this was indeed the view of some of those at the top of the UK government at that time.  Subsequent evidence would support this.  Some, perhaps many, hospital trusts, for example, have clearly told their staff not to accept people who are very old and fall into the most vulnerable category.  Likewise, Care Homes have been told to care for Covid-19 patients themselves, since they may not be accepted in hospital. The British Geriatrics Society thus notes (30th March) that:

  • “Care homes should work with General Practitioners, community healthcare staff and community geriatricians to review Advance Care Plans as a matter of urgency with care home residents. This should include discussions about how COVID-19 may cause residents to become critically unwell, and a clear decision about whether hospital admission would be considered in this circumstance”
  • “Care homes should be aware that escalation decisions to hospital will be taken in discussion with paramedics, general practitioners and other healthcare support staff. They should be aware that transfer to hospital may not be offered if it is not likely to benefit the resident and if palliative or conservative care within the home is deemed more appropriate. Care Homes should work with healthcare providers to support families and residents through this”

This  policy incidentally (and also helpfully for the government) lowers the daily reporting death rate because such people are not counted as “dying in hospital”.

3. The use of digital technologies may be used to identify those unlikely to be given hospital treatment.  The government quite swiftly introduced online methods by which people who think that they fall into the extremely vulnerable category could register themselves, so that they might receive help and such things as food deliveries.  Whilst aspects of this can indeed be seen as positive, it also seems likely that this register could be used to deny people access to hospital services, since they are most likely to die even with hospital treatment.  If true (and I hope it is not), this would be a very deeply worrying use of digital technologies.  Nevertheless, care homes are being forced to hold difficult discussions with those they are meant to be caring for about end-of-life wishes, and all doctors and medical professionals are increasingly having to make complex ethical decisions about who to treat (see Tim Cook’s useful 23rd March article in The Guardian).

4. The government has tried to pass the blame onto the scientists. Early on in the crisis I was appalled to see and hear government spokespeople (including the Chief Medical Officer – so beloving of systematic reviews) saying that they were acting on scientific advice.  As some of us pointed out at the time, there is no such things as unanimity in science, and so it was ridiculous for them to claim this.  However, they seem to have been doing so, and in such a co-ordinated manner, because they were seeking to shift the blame in case their policies went wrong.  Leading a country is a very tough job, and those who aspire to do so have to make tough decisions and stand by them.  Fortunately, this position by the government is no longer tenable, especially now that academics are competing visciously in trying to prove that they are right, so that they can take the credit. Nevertheless, there remains good science and bad science, and it is frightening how many academics seem to be pandering to what governments and the public might want to hear.  Tom Pike (from Imperial College), for example, predicted (against most of the prevailing evidence) in a pre-print paper with Vikas Saini on 25th March that if the UK followed China (which it clearly wasn’t doing) the total number of deaths in the UK would be around 5,700, with there being a peak of between 210 and 330 people, possibly on 3th April.  Although he retracted this a few days later when it was blatantly obvious that his model was deeply flawed, news media who wanted a good news story had been very eager to publish his suggestion that the pandemic would not be as bad as others had predicted (he certainly got lots of pictures published of himself in his lab coat).  Likewise, at the other end of the scale, the IHME in the USA predicted that the UK would have 66,314 deaths in total by 4th August, rising to a peak of 2,932 deaths a day on 17th April.  This  might have been wishful thinking, because on 7th April, UK reported deaths were only 786, which was substantially below their model prediction of around 1250.  By then, though, their research had already hit the news headlines with lots of publicity.  Subsequently (as at 11th April), they revised their predictions to a peak of “only” 1,674 deaths a day (estimated range 651-4,143) with a cumulated total of 37,494 deaths.  These differences are very substantial, and emphasise that scientists often get it wrong.  Put simply, the UK government cannot hide behind science.  They can try to take the credit, but government leaders must also admit it openly when they have been wrong with the policies that they make based on the evidence.

In conclusion, by sharing these thoughts I have sought to:

  • Ask the UK government to be more open and transparent in the information that it provides about Covid-19;
  • Plead with media of all sorts to use data responsibly, and to be critical of claims by governments and scientists who all have their own interests in saying what they do; and
  • Encourage everyone to work together for the common good, openly and honestly in trying to respond to the Covid-19 pandemic.

Above all, I write with huge respect for the many people in our NHS who have been working in the most difficult of circumstances to try to stem the tide of Covid-19.  Too many of them have already died; too many of them have become sick.

[Update 12th April: A report in The Times notes that “The death rate of Covid-19 patients admitted to intensive care now stands at more than 51 per cent, according to a study on a sample of coronavirus patients”.  The original report is by ICNARC, which showed that “Of the 3883 patients, 871 patients have died, 818 patients have been discharged alive from critical care and 2194 patients were last reported as still receiving critical care”. I should add that this is despite the very valiant efforts of our NHS staff]

[Update 14th April: Great to see that the BBC is at last reporting more responsibly about government reported deaths (based on those in hospital) being a serious underestimate of total deaths, and comparing trends of deaths with previous years – two useful graphs included and copied herewith below

deaths well above normal range - line chart      daily death updates are an underestimate since they exclude deaths outside hospital and are subject to reporting delays

Thanks BBC]

Updated 14th April

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Filed under Covid-19, digital technologies, UK, Uncategorized

Face masks and Covid-19: communal not individual relevance


face-masks-coronavirus-china-afpOne of the starkest differences between East Asian and European/North American responses to the Covid-19 pandemic has been in their differing attitudes towards face masks (used here generically, and differentiated from FFP3, also known as N95, respirators) : they are common in East Asian countries such as China, South Korea, Singapore and Japan, and yet are rarely to be seen in other parts of the world.  They have been part of the package of solutions recommended in East Asia, where infection and mortality rates have generally been quite low; yet they are absent in Europe and North America where rates are much higher.

World Health Organisation advice, followed assiduously by European governments and the U.S. Centers for Disease Control and Prevention (CDC) is clear:

  • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
  • Wear a mask if you are coughing or sneezing.
  • Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.
  • If you wear a mask, then you must know how to use it and dispose of it properly.

This is frequently interepreted in an abbreviated form, as by the BBC, to imply that “Only two types of people should wear masks: those who are sick and show symptoms, and those who are caring for people who are suspected to have the coronavirus”.

The case against wearing face masks comes down essentially to the argument that they will do little to protect someone from getting infected.  This is fundamentally an individualistic argument: “If I wear a mask it won’t be much good to me”.  However, from a communal perspective that is absolutely not the point; what matters is that if you wear a mask and are unknowingly infected it may help to prevent you spreading the infection to many other people.  Wearing a mask is about others not yourself.

A growing body of evidence is now suggesting that masks can indeed help to slow the spread of Covid-19:

  • The markedly different histories of infection between countries where masks are encouraged/enforced as part of a package of measures, and those where they are discouraged, is forcing researchers and policy makers to try to explain why.  Masks are an obvious possible answer.
  • It is increasingly being suggested that many Covid-19 carriers are assymptomatic.  They therefore don’t know that they might infect people, and so are going about their daily lives doing just that.  If they had been wearing masks, it is argued, this could reduce the number of people that they infect.
  • Dentists and healthcare workers in many parts of the world are encouraged or required to use masks both to provide some protection from patients, but also to protect patients from any infections that a dentist may have.  If such masks are seen to be offering patients some protection, then it seems strange to suggest that they offer no protection against a coronavirus such as Covid-19 (see reviews of surgical masks and N95 masks by Loeb et al., 2009, and more recently by Long et al., 2020)
  • Chinese doctors and scientists are increasingly confident that masks do make a difference.  In a recent interview, George Gao (Head of the Chinese Center for Disease Control and Prevention) has thus suggested that “The big mistake in the U.S. and Europe, in my opinion, is that people aren’t wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role—you’ve got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others”.

In societies such as the USA and much of Europe where the focus tends to be more on the “self” rather than the “community” it is scarcely surprising that individuals and their politicians see little value in masks; but in more communal societies, where there is  perhaps more care for others, then masks are seen as an important part of the armour against Covid-19.

Many governments fear that encouraging citizens to wear face masks would mean that there would be insufficient left for medical professionals to wear.   This, however, is rather a lame excuse.  Such governments could readily have put in place systems in early February to prepare to expand production of protective clothing.  It is not too late for them urgently to do so.  The BBC thus reports that “UK clothes makers say the government has wasted time in ordering personal protective equipment for NHS staff.  Fashion and textile firms believe they could have begun making gowns and masks for front-line workers 10 days ago”.

However, for those who do care about their neighbours and don’t want to disrupt the official production of masks for healthcare providers, an increasing amount of guidance is now available for making your own masks, as at:

These are clearly not going to be as good as masks made by companies to stringent regulatory standards (for UK see Regulatory status of equipment being used to help prevent coronavirus (COVID-19)), but they may well offer at least some protection to reduce the communal spread of Covid-19.  Pressure on demand is likely to become very much worse than it is at present, especially when imported masks are low in supply and often fail to satisfy these standards: recent reports (see for example Business Insider, 29th March) thus suggest that 600,000 masks imported from China have had to be recalled by the Dutch government because they are faulty.  In countries unable even to import masks from elsewhere, domestic production in line with international standards (see Wong, A. and Wilkinson, A., 2020) can be recommended.

Above all, the discussion should not so much be about “will I be protected?” but instead “how can I protect others?“.  It rather depends on what kind of society we wish to live in – especially for those who are left after this pandemic has run its course.

 

[Update 30th March – it is great to see that Austria has announced today, the day after I wrote the above, that it is to make wearing masks compulsory, and will distribute basic masks for free at the entrances to all supermarkets]

[Update 31st March – Tom Whipple in The Times notes comments from Prof Cheng at Birmingham University and Prof Cowling at University of Hong Kong in favour of wearing masks, although Prof McNally, also from Birmingham, expressed concern that this would be counterproductive since people would think they could still go out]

[Update 2nd April – David Shukman on the BBC News site: Coronavirus: Expert panel to assess face mask use by public.  The WHO should have acted much more quickly on changing its advice]

[Update 7th April – Link to Lydia Bourouiba’s important study on turbulent gas clouds and respiratory pathogen emission: coughs and sneezes can spread #Covid19 7-8 m; CDC guidance is only 2 m; masks might help https://jamanetwork.com/journals/jama/fullarticle/2763852. We really need to rethink social distancing…]

[Update 7th July – BBC Coronavirus: Don’t leave home without a face covering, says science body – why has it taken so long for people in the UK to argue vociferously for this?]

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Filed under Covid-19, Health, poverty, United Nations

Collaboration and competition in Covid-19 response


A week ago, I wrote a post about the potential of crowdsourcing and the use of hashtags for gathering enhanced data on infection rates for Covid-19.  Things have moved rapidly since then as companies, civil society organisations, international organisations, academics and donors have all developed countless initiatives to try to respond.  Many of these initiatives seem to be more about the profile and profits of the organisations/entities involved than they do about making a real impact on the lives of those who will suffer most from Covid-19.  Yesterday, I wrote another post on my fears that donors and governments will waste huge amounts of money, time and effort on Covid-19 to little avail, since they have not yet learnt the lessons of past failures.

I still believe that crowdsourcing could have the potential, along with many other ways of gathering data, to enhance decision making at this critical time. However the dramatic increase in the number of such initiatives gives rise to huge concern.  Let us learn from past experience in the use of digital technologies in development, and work together in the interests of those who are likely to suffer the most.  Eight issues are paramount when designing a digital tech intervention to help reduce the impact of Covid-19, especially through crowdsourcing type initiatives:

  • Don’t duplicate what others are already doing
  • Treat privacy and security very carefully
  • Don’t detract from official and (hopefully) accurate information
  • Keep it simple
  • Ask questions that will be helpful to those trying to respond to the pandemic
  • Ensure that there are at least some questions that are the same in all surveys if there are multiple initiatives being done by different organisations
  • Work with a globally agreed set of terminology and hashtags (#)
  • Collaborate and share

Don’t duplicate what others are already doing

As the very partial list of recent initiatives at the end of this post indicates, many crowdsourcing projects have been created across the world to gather data from people about infections and behaviours relating to Covid-19.  Most of these are well-intentioned, although there will also be those that are using such means unscrupulously also to gather data for other purposes.  Many of these initiatives ask very similar questions.  Not only is it a waste of resources to design and build several competing platforms in a country (or globally), but individual citizens will also soon get bored of responding to multiple different platforms and surveys.  The value of each initiative will therefore go down, especially if there is no means of aggregating the data.  Competition between companies may well be an essential element of the global capitalist system enabling the fittest  to accrue huge profits, but it is inappropriate in the present circumstances where there are insufficient resources available to tackle the very immediate responses needed across the world.

Treat privacy and security very carefully

Most digital platforms claim to treat the security of their users very seriously.  Yet the reality is that many fail to protect the privacy of much personal information sufficiently, especially when software is developed rapidly by people who may not prioritise this issue and cut corners in their desire to get to market as quickly as possible.  Personal information about health status and location is especially sensitive.  It can therefore be hugely risky for people to provide information about whether they are infected with a virus that is as easily transmitted as Covid-19, while also providing their location so that this can then be mapped and others can see it.  Great care should be taken over the sort of information that is asked and the scale at which responses are expected.  It is not really necessary to know the postcode/zipcode of someone, if just the county or province will do.

Don’t detract from official and (hopefully) accurate information

Use of the Internet and digital technologies have led to a plethora of false information being propagated about Covid-19.  Not only is this confusing, but it can also be extremely dangerous.  Please don’t – even by accident – distract people from gaining the most important and reliable information that could help save their lives.  In some countries most people do not trust their governments; in others, governments may not have sufficient resources to provide the best information.  In these instances, it might be possible to work with the governments to ehance their capacity to deliver wise advice.  Whatever you do, try to point to the most reliable globally accepted infomation in the most appropriate languages (see below for some suggestions).

Keep it simple

Many of the crowdsourcing initiatives currently available or being planned seem to invite respondents to complete a fairly complex and detailed list of questions.  Even when people are healthy it could be tough for them to do so, and this could especially be the case for the elderly or digitally inexperienced who are often the most vulnerable.  Imagine what it would be like for someone who has a high fever or difficulty in breathing trying to fill it in.

Ask questions that will be helpful to those trying to respond to the pandemic

It is very difficult to ask clear and unambiguous questions.  It is even more difficult to ask questions about a field that you may not know much about.  Always work with people who might want to use the data that your initiative aims to generate.  If you are hoping, for example, to produce data that could be helpful in modelling the pandemic, then it is essential to learn from epidemiologists and those who have much experience in modelling infectious diseases.  It is also essential to ensure that the data are in a format that they can actually use.  It’s all very well producing beautful maps, but if they use different co-ordinate systems or boundaries from those used by government planners they won’t be much use to policy makers.

Ensure that there are at least some questions that are the same in all surveys if there are multiple initiatives being done by different organisations

When there are many competing surveys being undertaken by different organisations about Covid-19, it is important that they have some identical questions so that these can then be aggregated or compared with the results of other initiatives.   It is pointless having multiple initiatives the results of which cannot be combined or compared.

Work with a globally agreed set of terminology and hashtags (#)

The field of data analytics is becoming ever more sophisticated, but if those tackling Covid-19 are to be able readily to use social media data, it would be very helpful if there was some consistency in the use of terminology and hashtags.  There remains an important user-generated element to the creation of hashtags (despite the control imposed by those who create and own social media platforms), but it would be very helpful to those working in the field if some consistency could be encouraged or even recommended by global bodies and UN agencies such as the WHO and the ITU.

Collaborate and share

Above all, in these unprecendented times, it is essential for those wishing to make a difference to do so collaboratively rather than competitively.  Good practices should be shared rather than used to generate individual profit.  The scale of the potential impact, especially in the weakest contexts is immense.  As a recent report from the Imperial College MRC Centre for Global Infectious Disease Analysis notes, without interventions Covid-19 “would have resulted in 7.0 billion infections and 40 million deaths globally this year. Mitigation strategies focussing on shielding the elderly (60% reduction in social contacts) and slowing but not interrupting transmission (40% reduction in social contacts for wider population) could reduce this burden by half, saving 20 million lives, but we predict that even in this scenario, health systems in all countries will be quickly overwhelmed. This effect is likely to be most severe in lower income settings where capacity is lowest: our mitigated scenarios lead to peak demand for critical care beds in a typical low-income setting outstripping supply by a factor of 25, in contrast to a typical high-income setting where this factor is 7. As a result, we anticipate that the true burden in low income settings pursuing mitigation strategies could be substantially higher than reflected in these estimates”.

 

Resources

This concluding section provides quick links to generally agreed reliable and simple recommendations relating to Covid-19 that could be included in any crowdsourcing platform (in the appropriate language), and a listing of just a few of the crowdsourcing initiatives that have recently been developed.

Recommended reliable information on Covid-19

Remember the key WHO advice adopted in various forms by different governments:

  • Wash your hands frequently
  • Maintain social distancing
  • Avoid touching eyes, nose and mouth
  • If you have fever, cough and difficulty breathing, seek medical care early

A sample of crowdsourcing initiatives

Some of the many initiatives using crowdsourcing and similar methods to generate data relating to Covid-19 (many of which have very little usage):

Lists by others of relevant initiatives:

 

Global Covid-19 mapping and recording initiatives

The following are currently three of the best sourcs for global information about Covid-19 – although I do wish that they clarified that “infections” are only “recorded infections”, and that data around deaths should be shown as “deaths per 1000 people” (or similar density measures) and depicted on choropleth maps.

 

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