If not now then when?

The question that PM Johson put this afternoon in his usual bombastic way is not the right one to ask but deserves an answer. Firstly in the negative by saying not when your senior medical team are about to say.

'We are facing an increasing epidemic at the moment so we need to act accordingly to limit transmission'. Whitty

Now is actually the worst time possible with the rising transmission of a variant whose full impact is still unclear and your medical staff saying the link to deaths is not fully broken. Yet the question has been asked and if I am saying no I feel I should respond and state my piece but the question itself is incomplete it shouldn't be when but how and when.

The problem is that in a morbid fascination with deaths the most obvious impact and easily measurable we are failing to recognise that the largest impact is not mortality but morbidity. It's not surprising, asbestosis, mines lung, have all been generational ticking time bombs that were not recognised at the time. Post viral syndromes have been around for a while too but what is emerging in Long covid is something that merges the impact of the two together and throws in a form of damage to the brain as well.

When Javid and Johnson talk about learning to go about living with it they talk in terms of flu but this is nothing like flu and as a virus that has only existed for less than 2 years we don't know what living with it in the long term actually means.

But even then what they are proposing today is not living with it at all. It's surrendering to fate (and the virus).

So back to the question and the when part first.

For a start, it's not before all members of the public aged 12+ have had a double dose of the vaccine if they want to receive it, for Wales that is likely to be mid-Sept and England a month later. Next rates need to be lowered to a level that TTP and sequencing can maintain control of any outbreaks and identify new variants. If we had shut India down with Pakistan and Bangladesh when the data indicated it should be that second criteria might now have been met. It's worth bearing in mind that in Wales today the rate and positivity measures mean we should be back in full lockdown. And third, we need to understand the relationship between vaccination and long covid. We are told that it breaks the link between hospitalisation and death but it is far too soon to know what impact it has on the incidence of long covid and even if it helps are we prepared to expose our children where long covid runs at about 7% to the risk.

This third question is the key latest ONS data 1 is suggesting 856k individuals are still experiencing symptoms 12 weeks after infection and of them, 385k individuals are still experiencing symptoms 1 year on. With delta infections rising exponentially we need to know how many more people will opening up expose to this risk before we allow it to let rip.

This all points towards a mid-September date for opening up if the data is moving in the right direction. But what should it look like and could we go further sooner the how part.

This is where there is scope to be sensible. Like it or not our government has already cast the dice on a huge experiment and whilst Delta is far more infectious than the native strain of 12 months ago we know open air is significantly safer. If we combine that with masks and open-walled marques and lateral flow testing then open-air events could go ahead through the summer.

Likewise with support to improve ventilation opening up venues for seated gigs with larger capacity should also be possible. This would however leave the nightclub sector high and dry as for Delta the risk remains too high. For this sector, additional financial support is a must. We also need to ensure that opening up is not a game of Russian roulette for workers and a prison sentence for the clinically vulnerable. Masks protect the people around them more than they do the user. If we expect people to work in pubs, drive busses and man supermarket tills we owe them a duty of care that is why masking legislation should unchanged. Likewise, TTP is essential and the use of check-ins at businesses should remain to facilitate effective backward tracing of infection. There should also be a moral obligation on people to use lateral flow tests prior to socialising. All of these measures place a duty on the individual but as often said the way a society treats its most vulnerable member is how you should judge the society. Taken together living with the virus could look like the usage of a series of non-pharmaceutical interventions which have a small impact on the individual in order to facilitate a greater societal good. Last Friday Independent Sage offered a range of 50-90k cases by 19th July depending on the doubling interval. Today the government opted for the optimistic lower end of this range in their press conference. The supposition is that death and hospitalisations is a much smaller percentage of infections but even a small percentage of a big number can exceed a big percentage of a small number if the number is large enough. In time we will have to adapt to Covid infection but that is not what is proposed today. In essence, the UK government offered up a survival of the fittest model with all responsibility placed on the individual in an environment that requires collective action. IT was an abdication of duty in the extreme.

References 1 Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK - Office for National Statistics (ons.gov.uk) 2 https://twitter.com/globalhlthtwit/status/1411795147243900928?s=20