Experiencing COVID-19

I had managed to avoid COVID-19 until a couple of weeks ago, but what seems almost inevitable some 30 months after it arrived on our shores has now come to pass. I have tested positive for COVID – despite all the care I tried to take. Many people have been far iller than I am, but I have always said that COVID is often much worse than is often thought, and I now have the living experience to show it (despite being triple vaccinated and one of the few people who still regularly try to wear a mask in crowded public spaces and in transport, not least to protect others). In line with UK government messaging that most people will not be seriously ill if they catch COVID and WHO guidance that “Most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment”, it is commonly held that COVID is no longer something that we should particularly worry about. After all, many people have no symptoms at all, and others scarcely know they have had it. Well, anyone who has experienced “mild to moderate” COVID will know just what it’s like – although few seem to have shared their COVID experiences online so that others can understand just what an unpleasant infection it can be – even for those not ill enough to be in hospital. Imagine the worst flu you have ever had, and then multiply it! Prepare to be completely exhausted for several weeks and beyond.

So, this is my COVID diary:

• Day 1. Began well, I had a negative Lateral Flow Test (LFT) since it was two days before I was due to fly overseas for a work commitment. As the day drew on, I developed a headache and tinnitus. I didn’t really think anything of it because all of us get headaches, don’t we?
• Day 2. Tested negatve with a LFT again, but the headache hadn’t gone away, and I started to get a runny nose and a sore throat. Some glasses of wine in the evening would hopefullly help me relax and serve as a delicious and gentle anaesthetic! After all, I had tested negative, and had probably just got a cold…
• Day 3. Woke frequently during the night with a painful sore throat, burning mouth, and tingling skin on my face. At one point, I could hardly swallow, so had plenty of water to drink, along with the paracetamol that I have taken regularly since (although not sure they make much difference!). At 6 a.m. I was suspicious, and took another LFT – after all, I wanted to fly in 8 hours’ time. I guess not unsurprisingly it rapidly showed up as being positive. Everyone who has experienced this will know the strange emotional feelings associated with a positive test. By now I was feeling really rather unwell: dizzy, the beginnings of a cough, brain a bit numb, unable to focus, tired… The clock was ticking though, and I somehow had to rearrange my flights, and let my colleagues know I would not be joining them. That took much of the morning, partly in bed and partly on the ‘phone. As the day progressed, I felt worse and worse: a pulsating headache, fatigue, and increasing pains throughout my body (especially where I had suffered sporting injuries in the past). After making a sandwich for lunch, it was back to bed and some sleep (facilitated by paracetamol). By the afternoon I felt a little better, and so crashed out on the sofa watching sport on TV. This was also an opportunity to order some food for delivery online the next day! But feeling slightly better was not to last! I somehow managed to make a simple meal, but as the evening progressed there was nothing for it but back to bed. My headache was much worse, sore throat increasingly painful, nose like a tap, and a cough starting along with pains across my chest. Lots of water by my bed to rehydrate. Blood pressure was very high…
• Day 4. Another restless night without much sleep. At one point my throat was so painful that I made a mug of hot lemon, ginger and turmeric tea. It seemed to help me a little to swallow, but my heart was pounding away heavily. I guess it was trying to pump blood around my body to counter the infection. I felt lousy as I eventually got up, and scraped together some cereal for breakfast. Hot tea helped again with the throat, and I even managed to make my must-have morning cappuccinno. As the day progressed, COVID seemed to be attacking different parts of my body in turn, looking for vulnerabilities. So, my throat felt better but the cough and pains across my chest were wose. I was having to get rid of increasing amount of phlegm, and my nose was still running out of control. Somehow I managed to put away the food delivery that came at lunch time, and make a simple salad. In the afternoon, I was able to do a little bit of digital catchup, but I couldn’t really focus, and became so tired. By the evening, I started to feel sick (perhaps the coronavirus leaving my throat for my stomach!), and didn’t feel like making any food for dinner, but forced myself to eat something – washed down with plenty of water (wishing it was wine). Beginning to wonder if I will ever feel well again…
• Day 5. I slept so badly – burning throat and frequent cough – not helped by noise of distant traffic (my hearing seems to be ultra-sensitive). Plenty of water, but even the lemon, ginger and turmeric tea that had helped the previous night didn’t seem to help at about 3 a.m.. My body, though, ached less, and I had energy to shower and shave when I got up later for the first time for several days. I tried to attend to some e-mails and join a Zoom call from bed with colleagues overseas at the symposium that I was meant to be attending. My brain couldn’t cope, and exhausted I crashed back to sleep. Small meal of pasta for lunch, but as the afternoon progressed I felt worse and worse again: headache, sore throat, really painful cough tearing at my chest/lungs (difficult to describe the horrible burning pain), difficult to breathe, very tired. I watched a film for nearly three hours, feeling ever worse. Paracetamol seems to make no difference. The rest of the day was a bit of a blurr – didn’t feel like eating any dinner, and just had lots and lots of water to drink. Decided to try hot honey, lemon and brandy before going to bed which seemed to help ease throat and coughing.
• Day 6: A wonderful thunderstorm in the night, seeing the flashes of lightening, hearing the crashes of thunder, and the torrential rain falling on the roof – made the world seem very real. Managed to get some sleep, albeit intermittently. Cooked an omelette for breakfast. Could see signs that I was gradually beginning to feel a little better – but persistent cough and tired chest, bringing up large amounts of dark-coloured plegm. At least the burning pain of coughing previously has receded. Losing track of days and time. Tried to sleep and rest in the afternoon; drank lots of water. Managed to eat a little dinner, and then watched a women’s international football match in the evening, but very tired by the end of the day. Wobbly on feet, and minor falls on stairs; pains in new areas, with many glands starting to ache for the first time. Tried honey, lemon and brandy again to help ease throat and coughing.
• Day 7: Am definitely recognising that I am feeling a bit better, but still very weak with a persistant cough, headache and runny nose. Still have no idea how long it will continue and how it wll progress. Had difficulty sleeping during the night, because of nose becoming regularly blocked which limited my abililty to breathe. Not easy to find a good position in which to sleep – changing sides regularly, and lying on tummy rather than back seemed to help breathing. Managed to attend an online team meeting for 30 minutes from bed – but any talking just elicited more coughing, and felt exhausted afterwards. Managed to check a few e-mails – feeling very grateful that I am not being sent many. By afternoon, became very tired again, and reverted to bed. Symptoms seem to be turning into bronchitis – so much coughing and phlegm, but grateful that the early vicious chest pains are no longer present. In evening even managed to cook a stirfry – so, must be feeling more together again. Advice from family and friends is consistent: take it easy for another week, and don’t try and do anything in the way of work because it will just prolong it. Tried ibuprofen for the cough, but no idea if it really worked.
• Day 8: Took ages to get to sleep last night – was coughing and having spent so long in bed over recent days wasn’t feeling very tired. Woke early and read news on my ‘phone. For the first time in a week am actually feeling as though I could do things. Boiled an egg for breakfast, and had some yoghurt and fruit as well. Felt very tired having done that – dizzy and faint, with just no energy at all. Back to bed to try to catch up with all the incoming e-mails. At least I can feel some progress towards normality, but headache has returned to accompany the omnipresent cough. Exhausted already; back to bed… Paracetamol… Announcement that the Queen had died provided a surprisingly sad focus to the day; perhaps made more so by all the uncertainties as to the future of our country and people.
• Day 9: the days are all blurring into each other. Woke coughing in the middle of the night, and had taken a long time to go back to sleep. Just about managed to contribute to a work Zoom call but very tired afterwards – too much coughing. COVID seems to have morphed into bronchitis – not as painful, but the coughing just seems to go on and on. It is so tiring. Little energy for anything. I had rearranged my flight overseas in case I was well enough to go this weekend, but there is no way I could possibly travel. Fortunately, I was able to cancel it for only a small charge and have it refunded back into our research grant. The news is full of the Queen’s death. Managed some soup for lunch, and then back to bed for some restful sleep. Walked up and down the garden a few times, and picked tomatoes, but that was about all I could do. Face and mouth tingling, but mainly just coughing and tired. Looked online to try to find more information about how long this will last – and apparently the expectation is two or three weeks, with there being nothing one can do other than paracetamol and drinking lots of water. Everyone has said, and I have said to others, make sure you don’t do too much too early; I can now really understand why.
• Day 10: longing for an undisturbed night – eventually managed to get some sleep between about 4 and 8 in the morning. Changed sensations again today – tingling mouth and cheeks, tinnitus back along with headache, but coughing miraculously a bit less. Watched the accession ceremony and proclamations at St James’s Palace and the Royal Exchange on TV, then lunch and back to bed. Just feeling so week and exhausted. No enthusiasm to do anything. At least I did a new online order for food tomorrow!
• Day 11: I did sleep quite well, apart from being woken from a deep deaming sleep at about 4 a.m.. Am gradually regaining my strength, but doing anything that requires thought or physical exercise make me really tired, brings on coughing, and leads to a headache. Am definitely better, but no inclination to do anything – wondering if the lethargy will ever go away. Went out to buy a commenorative newspaper (given I have tested negative, and was still wearing a mask this does not seem rash). Spent much of the day watching television: combining proclamations of Charles as the new King, while his mother’s coffin was driven from Balmoral to Edinburgh. I also managed to do some slides for a presentation in Nepal on Wednesday, and even had a go at cutting the grass (probably a big mistake). By the evening, my sore throat had returned, along with the familiar tingling in my mouth and face. Watched some TV to while the time away. Almost anything I do makes me tired, and I have no enthusiasm to get up and do anything.
• Day 12: Not much to report on; still gradually beginning to feel better, but whenever I try to do anything I start coughing and feel very tired. It’s a slow process. Cut my head open (not seriously, but it really hurt when I did it) as I fell into the edge of a window after breakfast; far from steady on my feet. Although all the NHS COVID guidance notes online say that you can expect to have a cough for several weeks and shouldn’t contact your GP unless seriously ill, I decided to make a telephone appointment with my GP – not least because I have mild underlying asthma, and was wondering how I should try to get rid of the cough. I was very impressed about what happened next: was offered an appointment at a GP Acute Illness Clinic at the local hospital in the late afternoon! Arriving by car just before the appointment, I phoned the number I was given and was invited straight in to be seen by a GP. He was very pleasant but clearly tired – it turned out that he had had COVID five times, but he was kind enough to say that none were as bad as I clearly still am. It’s very difficult to tell whether COVID-related bronchitis is viral or bacterial, but to be on the safe side he gave me a prescription for antibiotics (Clarithomycyn) and steroids (Prednisolone) over the next 5-7 days. Let’s see if they help, or if their side effects turn out equally badly!
• Day 13: Woke several times in the night – but fortunately managed to get back to sleep quite swiftly. Began the day trying to get the medicines I had been described, but local chemists did not have them in stock so I had to go further afield. Very tired on returning home, and so crashed out yet again. For someone usually so energetic, I am finding it very strange that I can just lie down and rest – no energy for anything else. If I try to read for more than a few minutes, I just lose interest and cannot concentrate. But by the afternoon, my coughing has indeed reduced significantly, though still have pains in my lungs and a tingling sensation on my face and chest. Increasing stomach pains might be a result of the antibios… Managed to cook an evening meal and then spent the rest of the evening stuck in front of the TV. Early to bed; very tired.
• Day 14: Two weeks in to COVID and for the first time can begin to see a light at the end of the tunnel. Perhaps the antbiotics and steroids are indeed working. Glad that I don’t seem to have any unpleasant side-effects. I slept really well, but woke soon after 5 to prepare for my online contribution to our ongoing work in Nepal – so envious of my colleagues working there, and sad at many levels for not being able to travel and be with them. It was great to see everyone in the workshop online, but the more I talked the more I coughed. I do hope that they felt my contribution was of value. I went back to bed shortly after 7, and fell blissfully fast asleep until nearly 9.30! The best sleep I have had for the last fortnight. Another online meeting between 10 and 11 finished me off – incredibly tired and lethargic. After a lazy day, I managed to stay awake to watch the most enjoyable England v Wales women’s rugby international. Overall, a day of definite improvements
• Day 15: Another good night’s sleep, and feeling well enough for my elder daughter and grandson to visit. Quite a lazy day, and was taken to a nearby children’s play area in Windsor Great Park in the afternoon which was most enjoyable! This was the first time I’ve been out in the sunshine for any length of time. However, it is crazy how tired I am feeling, with lots of symptoms (headache, sore throat, coughing, painful chest and lungs) having returned. Crashed out exhausted at the end of the day.
• Days 16-18: continuing slow improvement. Managed to do a bit of gardening, but still very tired. It was good, though, to be in the fresh air. No longer coughing very much, but permanent dull headache, and feeling faint and dizzy if I try to do anything. Wishing I had my usual energy. Last day of medication – very much hoping that I can eventually throw this off. Spent the morning of Day 18 watching the Queen’s funeral – uplifting, impressive and very moving… So many memories…
• Day 18-34: it is depressing to experience how slow the “improvement” is. I haven’t been able to do any real exercise (bike, walking, fitness routines) for the last fortnight. Even just walking up the stairs still makes me breathless. It is very frustrating. I’ve found this RCOT report on How to manage post-viral fatigue after COVID-19 quite helpful – in particular it emphasises the importamce of trying to have fun. Memo to myself: plan to do some fun things!

Resolving the COVID-19 crisis in the UK

The UK has the ninth worst death rate (per head of population) from COVID-19 in the world at 120 per 100,000, and this is the third worst of the 20 most affected countries (Johns Hopkins, 9 January 2021; just behind Italy and Czechia); the total number of deaths (within 28 days of a positive test) now being more than 80,000 BBC, 9 January 2021). More worryingly the number of new cases remains around 60,000 despite the recent partial lockdown, and deaths per day are currently over 1000 (UK Government, 9 January 2021). Furthermore, the number of deaths is likely to rise rapidly perhaps to around 2000 a day in a fortnight as the effects of the recent surge in infections work their way through over-stretched hospitals.

None of this need have happened if:

• the UK government had acted with leadership, foresight and wisdom over the last year; instead it has always acted too little and too late, often with calamitous mis-judgement (see critique of the government’s failures written in April 2020); and
• more people had responded to the crisis responsibly and wisely, caring for others as much as they did for themselves, and not trying to push the boundaries of what limited restrictions the government had put in place.

What little we know, but what we should have acted on

It is remarkable how much we still don’t know about COVID-19, despite all of the valuable research that has been done such as the creation of new vaccines and the discovery of treatments that can reduce death rates of the most seriously ill. However, we do clearly know enough for the UK government to have acted very differently over the last year. Among the most important things we do know are that:

• Countries that rapidly put in place comprehensive lockdown measures and keep them in place until the number of remaining cases is very low, have not only had lower overall mortality rates, but their economies are also recovering more quickly. The UK government has consistently gone into lockdown (or restrictions) too late, eased lockdown too early, and has never therefore got on top of the coronavirus. Particularly stupidly, the lockdown in November-December 2020 was nowhere near strict enough, and was foolishly eased in the anticipation that people could see their families over Christmas.
• Many countries with a history of using masks (such as China, including Hong Kng and Macau) or that have made them mandatory (such as Malaysia and Vietnam; but also many African countries) have been able effectively to limit or reduce infection rates. Much of the debate around mask use has been because of unwarranted confusion about whether masks reduce the chance of the wearer catching COVID-19, or of this actually protecting others (see my post in March on Face Masks and COVID-19). Selfish, individualist societies, where people care much more about themselves than about others and therefore don’t wear masks have generally suffered badly from COVID-19.
• The fetishisation of the R-number has caused unfortunate misunderstandings and led to many more deaths than would have otherwise been the case. The UK government has seemed to place inordinate emphasis on the reproduction number (R = the average number of secondary infections produced by a single infected person), rather than on the actual numbers of people dying. R is obviously important, but there is a huge difference in impact between a higher R number when total infections are low, and a lower R number when infections are high. Many more people in the short term are going to catch the infection (and die) when thousands are already infected even with a R-number well below 1, than will catch it if only a few people are infected and the R number is 2 or 3. This is crucial, because the government should have done much more to reduce new infections in the summer to virtually zero, and should have acted much more quickly in October when numbers started to rise again (lessons should have been learnt from the experiences of Australia and New Zealand).
• Too much reliance was placed on digital technologies. It is remarkable how the much-lauded NHS app (in its various incarnations) is now never mentioned by the government. Moreover, it was very expensive: in September 2020, it was estimated to have cost more than £35 million. The entire UK test and trace service has been a catalogue of disasters, but the expenditure on an app that was meant to be a silver bullet was truly misplaced, and the only people to have benefitted were the companies involved in developing it! As many people warned, digital technologies are invariably a solution in search of a problem, and the failure of previous digital initiatives should have been a clear warning to the government.
• Islands have a clear potential advantage in protecting their inhabitants from COVID-19. The UK has very clear borders that are relatively easy to “protect”, unlike so many other countries in Europe, and yet it has been very tardy in introducing restrictions for those croissing its borders (either way). Island states, especially New Zealand (only 25 deaths) and Iceland (only 29 deaths) with wise governmetns have been able to ensure that infections and deaths have been kept to a minimum by imposing very strict controls. Thus New Zealand specifies unequiovocally that “All people entering New Zealand must go immediately into managed isolation or quarantine facilities. They will remain there for at least 14 days and must test negative for COVID-19 before they can go into the community”.
• People respond to clear and simple messages, when they are delivered by trusted leaders. Unfortunately, the UK’s blustering leadership has prevaricated and vastly over-complicated the messages to those living in the UK during the pandemic. Things were made far worse, and trust evaporated, when Dominic Cummings did not resign following his breach of COVID restrictions in May 2020, which made many people in the country think that there was one rule for those in power, and another for everyone else. With confused (and weak) messages, alongside a growing belief that it was alright to tweek the rules a bit, it was scarcely surprising that so many people failed to act responsibly in the latter part of 2020 when COVID-19 ran out of control.
• It is not the new variants that have caused the recent dramatic rise in infections; it is people’s behaviour. Put simply, if everyone focused on protecting others from catching COVID-19, then regardless of the variant the number of infections would be minimised. Yet the government and news media persist in “blaming” the new variant for the recent dramatic increase in infections, which gives completely the wrong message to people. It is high time that we were open and honest about the fact that these recent very high infection rates have been caused primarily by people’s behaviour in December; if people were not giving the infection to others, then there would be no way that these others would catch COVID-19 – regardless of how infectious the variant is. We need to realise that perhaps one-third of infections are asymptomatic, and therefore that many people who feel perfectly well are probably giving COVID-19 to others.

What we should have done; but it’s never too late to take action

Based on the above, it seems fairly clear what the government should have done, but didn’t. This is not that dissimilar to what wise voices were saying back at the start of the pandemic (see my list in April of questions tbe government still needs to answer over its failures). Neil Ferguson and his team’s modelling back in March, although decried by some not only at the time but also subsequently, does indeed seem to have been quite an accurate prediction of what was going to happen, particularly as far as a second wave was concerned and especially given the lack of knowledge at the time about the precise dyamics of COVID-19. Anyone who read that March paper should have been left in no doubt that we were going to see at least 80,000 deaths from COVID-19. Those who argued vociferously and publicly otherwise should acknowledge their mistake and share some of the responsibility for the subsequent national vaccilation about the direction in which the pandemic was heading. We are already past this level, and many, many more are sadly going to die. Each one is a tragedy for their families and those cloe to them. There are absolutely no excuses for ayone saying that they were not aware of how serious the scale of the pandemic was going to be in November 2020-March 2021.

The creation of vaccines to counter the effects of COVID-19, as well as better treatment protocols identified over the past year, provide some hope for the future. However, drawing on the above evidence, the government still needs to take further steps immediately if the UK population and economy are going to be able to reduce the scale of suffering and damage that it has already caused. The following would seem to be wise actions (in approximate order of priority):

1. Lead rather than react; be ahead of the pandemic. The Government must take control of the situation, and show real and decisive leadership in tackling it. All too often the Prime Minister and his cabinet have dithered, and as a result failed to protect the British people. If tighter restrictions had been in place in December, there wouldm have been many fewer than the 417,570 people tested positive in the last seven days. They should have known and planned for the scale of what has happened. They are culpable for their failure.
2. Much tighter restrictions should be placed on personal mobility immediately, and they should be kept in place until the number of new infections is in hundreds rather than tens of thousands. This is likely to be a minimum of six weeks and possibly much longer, regardless of the hopefully positive effects of the vaccinations. The long term economic impact of COVID-19 would be far less severe with a shorter sharper lockdown than it will be if the government continues to try to pursue its on-off policy while maintaining relatively high levels of infection.
3. Face masks should be made compulsory for all people both outdoors and indoors at all times (other than in a person’s own home). This should apply to those jogging, running or cycling, as well as to those just walking. Sanitation points should be made freely available in all workplaces, shops, bars/restaurants and entertainment areas.
4. All people arriving in the UK should be required to show evidence of an appropriate negative COVID-19 test within 72 hours of arrival. As an island, the UK has the advantage of being able to manage its borders, and it needs to do so effectively so that additional infections are not brought into the country, especially of the inevitable new variants of COVID-19 that will emerge. It would also be a great gesture of our national care for others if we insisted on everyone leaving the UK also being tested.
5. The vaccination programme must be delivered effectively and efficiently. In general, the priority system seems broadly appropriate, but insufficient priority has been paid to those aged over 90, staff working for companies that provide care at home for the elderly, as well as GPs and other medical staff (all of these should be in the highest priority category) and indeed teacher. With 46,000 healthcare staff off work, an already over-stretched NHS has become even less able to manage the impending crisis. This is unacceptable carelessness on behalf of the government. Moreover, the vaccination policy and practice needs to be very much more transparent than it currently is.
6. A really efficient and effective test, trace and control system must be put in place once the number of new infections has reached less than 1000 a day. It is impossible for testing and tracing to work effectively with the level of infections that we now have. However, for longer term viability and success, once numbers have reduced to a manageable level (as they were for much of the summer of 2020) it is critically important that we have in place an appropriate and high quality epidemic montoring system that can prevent COVID-19 and its successor pademics from catching hold.
7. We should put in place now mechanisms to ensure that effective control against COVID-19 is in place for the latter part of 2021. This must ensure that sufficient vaccines are in place (preferably of the Oxford-AstraZeneca vaccine) for GP surgeries to deliver them effectively as they have done for may years with the annual influenza vaccine over the next year, and indeed in future years as well.

Each of these seven action points could have easily been put in place by the government during the summer and early autumn of 2020. It failed to do so and is therefore culpable for the excessive numbers of deaths that we are now seeing. It seems that Johnson, his advisers and senior ministers all seemed to prioritise a focus on getting an easy deal done over post-Brexit trade and relations with countries in the European Union, and therefore took its collective eye off the COVD-19 ball.

It is, though, not just the goverment’s fault. Everyone who has given COVID-19 to someone else is also partly responsible. We should not have needed the government to order us what to do. Surely, knowing what we do about COVID-19, we should all have acted reponsibly and wisely by limiting our personal contacts as much as possible. It is self-evident that we have failed to do this. We can, though, all make a difference now. Wherever we can over the next two months as many as possible of us should choose to stay at home. It only needs one contact to start a new chain of infection. Sadly, trying to circumvent the regulations that have been put in place seems to have become a national pastime; perhaps this is Dominic Cummings’ lasting legacy. Any excuse for not adhering to them seems to be acceptable to the person making it. In part this is again the government’s fault. Why on earth, for example, was “local area” not defined when the government permitted outdoor exercise within it? For one person it is somewhere within a 30 minute drive; for another it might just be within walking distance of home. However painful it is, we all need to act even more responsibly than we did in March-April. I hope Chris Whitty (the UK’s Chief Medical Officer) is right when he said on BBC Radio 4 this morning that we are at the peak of the outbreak, but I fear he is not. Given the very large number of new infections that we are still having, death rates are bound to increase further for at least two more weeks. At least Matt Hancock said yesterday that “every time you try to flex the rules that could be fatal“; such a shame that this message has not been clearer from the government before. We, the people, need to act where the government has failed. We can make a difference, but we need to care for each other more than we do for ourselves – as the brilliant staff in our NHS strive to do every moment of every day.

Our “winter of discontent”…

Back in July, and indeed long before then, many of us were warning that we had to spend the summer working incredibly hard to ensure that the UK would be able to be resilient in the face of the likely rise in COVID-19 infections. It seems instead that the government took its eye of the ball, hoped that COVID-19 would somehow go away, and instead concentrated on trying to impose its will on the European Union over the Brexit trade negotiations.

In September (the 18th), when I was feeling particularly disgruntled with the incompetence and stupidity of our government, I therefore posted on Facebook a list of some of the things that I feared might happen over the next year under the heading “Now is the winter of our discontent… (Shakespeare, Richard III). I wonder how many of these will coincide in the UK over the next few months”. Having been for a long autumnal walk today (the picture above), the day after our Prime Minister announced a new 4-week lockdown from 5th November, I just thought that I would also post them here as a record of what happens over the next few months. I so hope that I am wrong, but I will update the content periodically to see what happens: green means that fortunately my fears were ill-founded; red indicates that sadly I was correct; and pink indicates that there is some evidence that we are heading this way! I should stress that these are not predictions, but instead imaginations of what a “perfect-storm” would look like. Already, our government has indebted future generations for years to come. There is no doubt that things will get very much worse before there is even a glimmer of hope that they will improve.

• Dramatic increase in serious COVID-19 cases leading to overwhelming pressure on hospitals;
• Crisis over Brexit negotiations resulting in serious trade disruptions and collapse in value of the pound (not least on 20th December, in large part because of coincidence of rapid surge in new COVID-19 strain with stalled Brexit negotiations, Port of Dover announces ferry terminal closed to traffic leaving UK; massive lorry queues at Dover as borders closed; however agreement on a Brexit deal on 24th December slowly improved matters; but subsequently border queues and bureaucratic changes led to further problems in January 2021 as evidenced with BBC report on M&S, shirt exports in The Times, and Michael Gove the Cabinet Office Minister stating on 8 January 2021 that there will be significant disruption at borders)
• Influenza pandemic (partly because of insufficient vaccines available) coinciding with COVID-19 pandemic causing additional crisis for NHS;
• Food shortages (resulting from trade disruptions) leading to rising thefts from supermarkets and shops; (BBC News: trade disruptions at Felixstowe, 14th November 2020; BBC News: Brexit increasing food supply chain costs)
• Serious flooding in much of lowland England as a result of heavy rains in October and November (BBC reports heavy rainfall and risk of flooding, 3rd October; BBC also reports homes evacuated in South West after downpours and flooding on 19th December; and serious flooding in Bedfordshire and elsewhere reported on Christmas Day – BBC)
• Increasing power outages resulting from gas shortages, lack of sunshine for solar power, and storm damage;
• Standstill caused by heavy early snowfalls in late December (Glad that this did not happen)
• Mass graves dug in major cities because crematoria and mortuaries are overcome by demand (not yet, but overflow mortuaries were being created in early 2021 – BBC News: emergency mortuary in a Surrey woodland, 11th January 2021)
• Very significant riots as more and more people realise that Brexit was a huge mistake;
• Her Majesty Queen Elizabeth II dies of COVID-19 complications, and mass demonstrations against Prince Charles lead to his resignation and the declaration of a Republic;
• Northern Ireland joins a united Eire;
• Scotland and Wales declare unilateral independence from the UK, and form a wide-ranging mutual interest pact…

Who will be the sun of York to turn this winter into glorious summer?

Latest update 14th January 2021

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).

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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

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):In 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 day.  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!

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

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

[Updated 19th June 2020]

 

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]

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.

 

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[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.

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 21-23^o 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]

Questions the UK government must answer over Covid-19

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]

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

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 21^st 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

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.

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.

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

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.

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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 15^th 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 (13^th 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/.