After a year of COVID-19, what have we learned?
As we reach the Day of Reflection (23 March 2021) to mark the anniversary of the COVID-19 pandemic, it is worth asking ourselves why and how we got here. This pandemic has been more than a year in the making and how it came about is an extremely contentious and divisive subject. We can speculate how far back we need to look to pinpoint when a pandemic of this nature was first anticipated. For the purposes of this article, I will focus on a few key dates from recent years as well as the past year of the pandemic itself.
Swine Flu (H1N1) and the WHO definition of a ‘Pandemic’
On May 4th 2009, the World Health Organisation (WHO) changed their definition of an influenza pandemic by removing from its description the resultant impact of “enormous numbers of deaths and illness”. This change was done just before, and some would argue to enable, the declaration of a pandemic from the outbreak of the ‘swine flu’ (H1N1) influenza a month later. The projected impacts of the virus were bleak and consequently many countries purchased vast, albeit underused quantities of vaccines to protect their populations. Despite this, the death toll was low and yet millions of people were vaccinated with drugs approved following minimal clinical trials and with indemnity provided to their manufacturers. The following Channel 4 clip is good introduction to this debacle. Sadly, some of the recipients of these drugs suffered adverse life-changing reactions such as developing narcolepsy.
In 2010, a year after the Swine Flu outbreak, the Rockefeller Foundation released a report entitled Scenarios for the Future of Technology and International Development. The report examined the use of technology in addressing future world scenarios. One of these scenarios entitled ‘Lock Step’ envisaged a future influenza pandemic far worse than the prior year’s H1N1 outbreak. It forecast the damaging impact this would have on worldwide economies and international travel. It describes how countries, such as China, fared better from imposing measures such as quarantines and mask-wearing on its populations. Even as the pandemic abated, authoritarian government control remained and, in some instances, intensified.
Jump ahead to 2019 and the WHO-affiliated Global Preparedness Monitoring Board (GPMB) released their first annual report A World At Risk. The report is intended to capture the world’s ability to respond to major health threats whilst highlighting actions for world leaders to take.
The report set out a number of progress indicators for the coming year, including the following recommendation:
The United Nations (including WHO) conducts at least two systemwide training and simulation exercises, including one covering the deliberate release of a lethal respiratory pathogen.
Pandemic Exercises: Clade X and Event 201
Speaking of simulation exercises, one such had happened in May 2018 and another even more significant a month after the first GPMB report, in October 2019. The first exercise, hosted by the Johns Hopkins Center for Health Security, focuses on responding to the intentional release of the novel virus Clade X which causes 2% of the global population to die, economic devastation, famine and civil unrest.
The following year on 18 October 2019, Johns Hopkins along with the World Economic Forum and Bill & Melinda Gates Foundation hosted the next pandemic exercise, Event 201.
Event 201 simulates an outbreak of a novel zoonotic coronavirus transmitted from bats to pigs to people that eventually becomes efficiently transmissible from person to person, leading to a severe pandemic. The pathogen and the disease it causes are modelled largely on SARS.
This exercise again focuses on the health, economic and societal impact of a pandemic and touches on solutions involving restricting freedom of movement and tackling misinformation, especially online by ‘flooding the zone’. Watch the highlights here.
Prior to these exercises, the National Health Service (NHS) and partners in England had also hosted its own pandemic influenza exercise on 18–20 October 2016, entitled Exercise Cygnus. The report from this exercise was not published until 2020 after considerable pressure had been placed on the government to do so. The exercise found that the UK preparedness for a flu pandemic was ‘insufficient’ with particular focus on the care homes sector.
Wuhan and the Outbreak
In late 2019, a number of respiratory illnesses were recorded in Wuhan, China. At the start of 2020, it transpired that sufferers were infected with a novel coronavirus subsequently labelled SARS-CoV-2. In the following weeks cases were identified in neighbouring countries and that human-to-human transmission was occurring. By the end of January, Wuhan and other parts of China were in ‘Lockdown’ and the illness had reached Europe.
Early February saw the curious case of the Diamond Princess cruise ship departing from Hong Kong. As one of the passengers had tested positive for coronavirus, the ship was immediately quarantined for 14 days. Quarantines were to be a common response to outbreaks of the virus and in late February the northern region of Italy was placed under strict lockdown in an attempt to stop the spread of the respiratory disease now known as COVID-19. Particular focus was placed on Bergamo province in the region of Lombardy where stories were reported of the army being called in to assist with the removal of corpses. In early March strict public health measures were introduced in the whole of Italy with other countries in mainland Europe following suit. At the same time, the Director General of the WHO declared COVID-19 a ‘global pandemic’.
The status of COVID-19 in UK
The UK considered itself to be a few weeks behind Europe and as such its initial response was to allow the virus to circulate to create “herd immunity” in the population. However, on 13 March it was announced that local elections would be suspended for a year. Despite the measures being taken, particularly in healthcare, the status of COVID-19 as a high consequence infectious disease (HCID) was downgraded on 19 March.
Healthcare policy and communications
On 17 March the NHS asked hospitals to cancel all non-urgent operations and discharge all medically fit patients with the aim to free up 30,000 hospital beds. Based on ‘emerging international and UK data’, the NHS was told to prepare for large numbers of inpatients requiring respiratory support. The process for expedited discharge of patients was set out in updated COVID-19 Hospital Discharge Service Requirements on 19 March. The health service was told that “whatever extra resources our NHS needs to cope with coronavirus — it will get.”
Lockdown and three weeks to ‘flatten the curve’
Two days after the passing of the Coronavirus Regulations, the British Prime Minister addressed the nation on 23 March instructing people to stay at home, effectively beginning the first UK lockdown in response to COVID-19. Some critics have since claimed that England had waited too long to lockdown and that its previous ‘herd immunity’ approach was irresponsible. However, it later came to light that locking down the nation was always inevitable as advertising contracts had been agreed weeks prior to the decision.
The initial period of lockdown was to be three weeks to ‘flatten the curve’, effectively describing how the interventions were intended to delay and reduce the impact of the pandemic on the health of the nation and healthcare services. The Health Secretary announced plans to construct Nightingale Hospitals around the country to provide additional critical care capacity. Lockdown lasted longer than three weeks with gradual easing of restrictions starting from early June but with a number of non-pharmaceutical interventions (NPIs) to remain in place, such as ‘social distancing’. The compulsory wearing of face-coverings was introduced in mid-June despite previous evidence indicating their limited effectiveness, one of many U-turn announcements throughout the past year.
Scientific Advisory Group for Emergencies (SAGE)
Coronavirus regulations are allegedly ‘led by the science’, much of which is informed by the Scientific Advisory Group for Emergencies (SAGE). SAGE, who has been advising the government on such events since the aforementioned 2009 flu pandemic, is comprised from the field of academia and practice. The SAGE sub-group Scientific Pandemic Influenza group on Behaviour and Communications (SPI-B&C) has evidently had a key role in informing policy. Minutes from one of the SAGE meetings early in the pandemic even suggested the following:
“The perceived level of personal threat needs to be increased among those who are complacent, using hard-hitting emotional messaging.”
The response was mirrored around the globe, a worldwide strategy to increase the levels of fear to justify the draconian measures being implemented in the name of public health. To support the delivery of this fear-inducing messaging the government issued specific broadcasting guidelines via its Office of Communications (Ofcom).
Consequently we have seen one-sided reporting and reduced journalistic scrutiny of government policy on COVID-19. This messaging has had a profound impact on suppressing public scientific debate as captured by this BBC Newsnight piece from last November.
Supply of Personal Protective Equipment (PPE) and ventilators
Despite the considerable amount of resource committed to dealing with COVID-19, there were logistical challenges with regards to supplying personal protective equipment (PPE) to health and care staff and concerns about the availability of mechanical ventilators for treating patients in critical care. Despite the demand for ventilators it later transpired that outcomes are better with non-invasive treatments and that the decline in the usage of ventilators coincided with reduced chances of dying.
Test & Trace and the definition of a ‘Case’
Another of the key resource-heavy measures deemed necessary in measuring and managing the impact of COVID-19 is testing to identify the spread and volume of coronavirus cases. The health secretary began an ambitious program in April 2020 with the target of achieving 100,000 tests per day by the end of that month. Testing volumes have since exceeded 1 million a day. COVID-19 cases are identified predominantly through swab sampling and analysis using polymerase chain reaction (PCR) testing rather relying on clinical diagnosis. Due to this approach positive cases can be identified in people without symptoms.
Testing of asymptomatic subjects is deemed necessary on the basis that transmission can occur without symptoms, despite it not previously being considered a driver for the spread of respiratory disease and without scientific evidence of its occurrence. The identification of cases without symptoms is also made possible through the PCR testing methodology which does not distinguish if positive results are infectious. Results may well be identifying that traces of the virus that are present from weeks or even months prior to swabbing. Many concerns have also been raised regarding the rate of false positives (where a person is not sick, but the test inaccurately reports that they are) produced by the PCR tests.
The identification of cases is the driver of prevalence and also a key component in determining whether deaths are associated with or caused by the presence of coronavirus. From first reporting, the occurrence of COVID-19 deaths were reported for any death of a person who had previously tested positive for coronavirus at any time, effectively meaning after testing positive one could never recover from COVID-19. This anomaly was changed to report deaths within 28-days of a positive test and/or where COVID-19 was mentioned on the deceased’s death certificate.
Excess mortality is a more comprehensive measure of the total impact of the pandemic on deaths than the confirmed COVID-19 death count alone. Excess deaths are defined by the volume of deaths observed above the expected amount in ‘normal’ conditions, which is usually based on the prior 5-years’ average.
The chart below from the Office for National Statistics (ONS) present the level of excess deaths by place of death for the first few months of the pandemic in England. Notably the greatest excess occurred in care homes and private homes.
There has been considerable controversary surrounding care homes deaths given that many patients were discharged to them from hospitals at the start of spring and subsequently many residents died without seeing their relatives due to the tight societal restrictions that were put in place. It also came to light that blanket do not attempt cardiopulmonary resuscitation (DNACPR) orders were placed on care home residents at the start of the pandemic causing potentially avoidable deaths.
The weekly trend of excess deaths since the start of last year tells an interesting tale. It seems strange that a disease which had been circulating during the winter months would not impact mortality until spring when a pandemic was announced, and lockdown restrictions were put in place. As there was no pre-lockdown excess mortality some would argue that these additional deaths are due to lockdowns rather than COVID-19.
While excess deaths in hospitals and care homes have come in ‘waves’, they have occurred in private homes every week since the start of the pandemic. This is most likely to be the effect of reduced access to healthcare due to NHS policies or pandemic-induced population behaviour.
The classification of COVID deaths has courted considerable controversy. WHO guidelines issued in April made it clear that COVID-19 should be recorded on death certificates where it or any coronavirus caused, or is suspected to have contributed to, the death. As previously mentioned, COVID-19 death also includes any within 28 days of a positive PCR test. Hospital deaths in England are reported across different breakdowns including ethnicity, gender and age group and the presence of a pre-existing conditions. The data charted below indicates that 96% of COVID-19 deaths occurring in hospital were for patients with one or more pre-existing condition and more than half were over the age of 80. At the time of reporting, hospital deaths from COVID under the age of 60 with no known pre-existing condition stands at 691 out of a population of 56 million people.
Wider impact on healthcare
The NHS is constantly under pressure for its resources, especially during the winter months. Plans for the 2020–21 NHS contracting year were put on hold after the pandemic was declared and as described above, the NHS was tasked with ‘clearing the decks’ to create capacity for a wave of COVID-19 patients. At the same time, the NHS began collecting daily COVID-19 data from hospitals regarding patients and staff with the number of hospitalisations being a key metric. The definition of a COVID-19 admission included patients with suspected COVID symptoms and those testing positive using PCR. It is possible to count patients twice if first suspected and then confirmed as having COVID-19 and it is also worth noting these figures include a significant proportion of asymptomatic cases. The peak of COVID inpatients occurred in mid-April and reached over 21,000. However, of the swiftly erected Nightingale hospitals, only London’s was used, and the peak of inpatients was 33 out of 500 available beds on 19 April. In the second wave, the NHS encountered a higher volume of COVID-19 positive patients in hospital. However, the proportions were very similar to spring as this time around elective treatments were not routinely cancelled.
The announcement of a ‘pandemic’ and the accompanying mantra of “stay home and protect the NHS” certainly reduced the emergency care burden on the NHS. The below Accident & Emergency (A&E) statistics from the past two years indicates that emergency attendances and admissions dropped significantly in spring 2020 and have yet to recover to pre-pandemic levels.
Call to NHS 111 services increased significantly following the announced arrival of coronavirus, however the number resulting in ambulances being disposed did not increase indicating a rise in public anxiety around COVID rather than the presence of severe symptoms. In fact, ambulance conveyances to emergency departments dropped in the spring months.
Whilst it is acknowledged that more severely ill patients need critical care treatment, the majority of COVID positive inpatients are treated in general NHS beds. During spring 2020 a daily average of 10,000 NHS general beds were closed (some were repurposed as critical care) compared to previous quarters and occupancy levels were less than two-thirds of the corresponding quarter in the prior year. To quantify this there were over 3 million unused bed nights in quarter one, the height of the pandemic. Some bed closures were also due to a high level of staff sickness during the first wave. It is perhaps surprising then that there was not a corresponding increase in bank and agency shifts to cover these absences.
At the time of writing, the impact on other areas of healthcare has been profound. The number of patients waiting over a year for NHS treatment has increased from 1,600 to 304,000 in the space of year and cancer treatments also significantly reduced during the spring months. Reduced access to primary care also saw a significant drop in face-to-face GP consultations and referrals to secondary care during the same period. Whilst NHS services are now focused on recovery, the impact on vulnerable and marginalised groups has been extreme and a pandemic of mental ill-health is anticipated to arise from this difficult period.
Vaccinations and the 2nd Wave
The development of vaccines to treat an enigmatic illness began in January 2020, two months before COVID-19 was declared a pandemic. The genetic code was released by China on 11 January 2020 with the testing protocol being approved just two days later. All this despite messaging to the contrary from China’s Centre for Disease Control (CDC) a year later that the virus had not been isolated.
The UK government ran a consultation in September 2020 on changes to Human Medicine Regulations to support the rollout of COVID-19 vaccines. This set out the intention to grant approval for ‘temporary authorisation of the supply of unlicensed products’, strengthen manufacturers’ protection from liability, expand the workforce who can administer vaccines and lift the ban on promoting unlicensed medicines.
Around the same time the previously advocated strategy for acquiring natural ‘herd immunity’ was no longer possible according to the World Health Organisation who changed their definition to state it could only be reached through vaccination.
The first vaccine gained UK approval in early December, the administering of which began a week later starting with the elderly, clinical vulnerable and front-line health and care workers. Unfortunately the impact was not swift enough to prevent a second wave of excess COVID-19 deaths, many of which occurred in hospitals and care homes.
The fact that the rise in deaths occurred at the same time as the mass vaccination roll-out gained some attention from independent journalists. There have also been many cases of spikes in deaths in care homes following residents receiving their COVID-19 vaccinations, despite claims that the correlation did not prove causation. Applying the same logic that is used for COVID-19 deaths, it would be interesting to know the number of deaths within four weeks of vaccination.
International data and comparisons
While many may suggest that the impact of COVID-19 may have been worse without coronavirus restrictions, it is hard to ignore the approach taken by Sweden. Unlike the majority of European countries, Sweden did not impose lockdowns and subsequently did not fare any worse in terms of mortality from COVID-19. Perhaps unsurprisingly, this is still a topic of much debate.
Direct comparisons can also now be made between American states where some remain completely open, and others are still under degrees of lockdown with mask-mandates in public places. Despite far fewer rules and restrictions, Florida lands somewhere in the middle of all states on a variety of coronavirus metrics and has fared particularly better than California, who are in still in lockdown, in recent months.
Perhaps the most radical and ‘light touch’ response to COVID-19 was present in Tanzania where the recently deceased President, John Magufuli, proposed three days of prayer to combat coronavirus and no lockdown measures. Magufuli had previously questioned the accuracy of PCR testing for coronavirus by returning positive test results for a goat and a pawpaw fruit.
The presence of COVID-19 has also had an impact on the prevalence, as well as treatment, of other diseases. As COVID is diagnosed predominantly by testing rather than symptoms there is an increased likelihood of misdiagnosis. So-called ‘experts’ declared that the reduction in flu cases this winter was due to the use of hand sanitiser, masks and social distancing. This claim is made despite the same measures not eradicating coronavirus. The rapid decline in flu is also a worldwide phenomenon which coincidentally began at the start of the COVID-19 pandemic.
Pandemic or Plandemic?
Considering the N1N1 Swine Flu debacle it is evidently possible to declare a pandemic when arguably it is not and while that one fizzled out the preparations for the next one to be more impactful was soon well under way. The script was being written for a global High Impact Respiratory Pathogen Pandemic.
The response to the threat of COVID-19 was mirrored across the globe with national governments in Lockstep. Whilst the UK wished to appear to be taking a different approach, lockdown was always inevitable. The UK government signed multi-million pound advertising contracts weeks before lockdown and before COVID-19 was even declared a ‘pandemic’.
UK government messaging and healthcare policy had a profound impact on the treatment of the sick in all corners of society. There was ample capacity to treat people in hospital rather than force them to die in homes and care homes. If there was truly a pandemic why would it wait months to impact excess mortality and coincide with lockdowns, withdrawal of healthcare, mass discharge of the elderly, increased use in DNACPR orders, mass fear-inducing propaganda while people are isolated and housebound?
The NHS has been over-protected & over-burdened by nonsensical practices implemented through the lens of COVID-19. It begs the question: is this an over-reaction to an over-exaggerated threat that ultimately does more harm than good? The cure so far has been worse than the disease.
Many of the decisions around the handling of COVID-19 appear to have been political rather than in the interests of public health. National and international comparisons and the reasoned voices (when they can be heard) critiquing government policy indicate that the dominant pandemic response has been to the benefit of world corporations rather than world citizens.
Personal freedoms are being restricted around the globe, all in the name of combating an illness no more deadly than one it appears to have replaced. The pre-scripted world of tighter top-down government control and more authoritarian leadership is now much more than just a pandemic scenario.
This article was first published 23 March 2021.