13 September 2020 — Dr Malcolm Kendrick
[Winter is coming]
In the flu pandemic at the end of World War One, the average age of death was twenty-eight . In the UK, the average age of death from COVID19 is eighty-one for men, and eighty-four for women. Which is older than the average life expectancy in parts of the UK. These data are from the Office of National Statistics (ONS), as analysed and reported in the Daily Mail .
[I do not usually reference newspapers for scientific data, but this article is very clear and understandable for the lay reader].
The risk of dying if you get infected and have serious symptoms, requiring some medical actions – the case fatality rate (CFR*) – also rises exponentially as you get older. In Italy, in the early stages of the pandemic, the CFR for those under twenty-nine was zero per cent. Rising to twenty per cent in those over eighty .
[*this figure changes over time. It always falls as more and more people are tested. See previous blogs also about mixing up CFR with Infection Fatality Rate (IFR)]
I am not getting into an unwinnable argument as to the value of human life at different ages. I am simply making the point that COVID19 is, for reasons not well established, vastly more serious in the elderly population. This is very different from previous epidemics.
COVID19 also targets those with significant underlying medical conditions. A recent report from the Centers for Disease Control and Prevention (CDC) in the US, found that ninety-four per cent of patients who died from COVID19 had other ‘health conditions and contributing causes.’ 
In essence, we know that COVID19 is a disease that is both significant and deadly in the elderly population. Particularly the elderly population with underlying medical conditions. For those of working age – who are otherwise healthy – COVID19 is far less serious. The risk appears to be lower than for influenza. In children, and those under forty, the risk is almost non-existent.
Therefore, it is relatively straightforward to identify pretty accurately those who we need to help protect from COVID19, and those who we do not.
On this basis I am going to recommend that the best way to protect the vulnerable elderly is to build up immunity in the younger population, in order to stop the spread throughout the whole community. If eighty per cent of the population under seventy were to get infected, this would stop transmission in its tracks, and COVID19 would be gone.
However, what we are doing currently is to lockdown ever more tightly to stop the spread. Whether or not this is working is unclear. However, let us assume that it is doing so. Then, I would argue that we are doing precisely the wrong thing at precisely the wrong time.
It is true that in recent weeks, positive infection tests have risen rapidly. However, deaths have not nor have hospital admissions. In the month of August (which is as far as the Office for National Statistics figures go), in the under thirty age group, there was one death .
Of course, if more and more people get infected, and more elderly vulnerable people get infected, there will eventually be an increase in deaths. Therefore, what we need to do right now – before winter comes – is to encourage everyone who is fit and well and under the age of seventy (slightly arbitrary figure) to take the masks off, get together and spread this virus far and wide.
At the same time, all of those who are older and/or vulnerable should self-isolate, and this should be rigorously encouraged, and supported. How long would it take to infect the rest of the population?
Using widely accepted figures. If the R number is three (average number of people an infected person will go on to infect), and the serial interval is four days (time from becoming infected to infecting others), then we can do a little thought experiment.
We start with the number of people currently infected. Today, Sept 11th there were 3,539 positive tests in the UK. Assuming people are infectious for a week, then the minimum number of people who have COVID19, currently, who could spread it is 3,539 x 7 = 24,773.
This assumes we have detected every single infected person in the UK, which is not possible, so my 24,773 figure is a major underestimate of the true starting point.
If the R number is three, and the serial interval is four, we would treble the number of cases every four days. We start on day one with 24,773 infective people.
Day one = 24,773
Day five = 74,319
Day nine = 222,957
Day thirteen = 668,871
Day seventeen = 2,006,613
Day twenty = 6,019,839
Day twenty-four = 18,059,517
Day twenty-eight = 54,178,551
That’s it. Done in a month. Of course, it doesn’t quite work like that. As more and more people get infected, there are less people left to infect so the R number drops. We also know that a number of people have already been infected. How many? Who knows.
However, the general principle stands. We could protect the vulnerable elderly by creating sufficient immunity in the rest of the population, ensuring that the elderly are shielded at the same time, and it could be done rapidly.
Matt Hancock (UK health secretary, for those reading this blog in other countries), made the utterly insensitive comment urging people not to kill their granny:
‘Young people have been urged by the health secretary not to “kill your gran” by spreading coronavirus after an increase in cases led to calls for mass testing of students.’
Has this man been on a course on how to really and truly insult and upset your electorate? If not, then he is clearly just a natural.
Leaving that to one side, Matt Hancock should be urging young people to get infected and ‘protect your granny’ – and also your grandpa. Because grandpas are people too.
Yes, I know, some people, many people… most people? Will be upset by what I have written. How can you possibly encourage people to go out and get infected? Do you want people to die?
No, I want the least possible number of people to die of this awful disease, and its terrible consequences. I also want to stop lockdown as soon as possible because I know that lockdown kills people. Currently it is killing far more than COVID19. Forgetting the economy, forgetting the social destruction and loss of jobs and livelihoods, there are terrible things happening to lives.
Here is what the UK Parliament was told, early on in the lockdown:
‘A global surge in domestic abuse has been reported during the coronavirus pandemic, as those living with domestic violence face greater risks at home during lockdowns, and support services are harder to reach and to provide.
The UK has followed the global pattern of rising domestic abuse risks during the crisis: calls and contacts to helplines have increased markedly and evidence suggests incidents are becoming more complex and serious, with higher levels of physical violence and coercive control.
Counting Dead Women has calculated that there were at least sixteen domestic abuse killings of women and children between 23 March and 12 April.’
Young children are far more likely to die at the hands of their parents than they are to die of COVID19, and young women are far more likely to die at the hands of their abusive partners. Vulnerable children are far safer at school than at home. Yet, we are locking them in their houses.
So, I would turn the whole argument around. Why are we killing children with Lockdown? Get rid of the virus, now, get rid of lockdown now, and allow them to live. Allow the rest of us to have a job, and a future.
As for our elderly people, trapped in houses and Care Homes, unable to see their families. Get rid of this virus now, get rid of lockdown now, and allow them to live. To those who believe they occupy the moral high ground by demanding more lockdowns, more protection etc. I believe that you are failing to protect anyone.
The fact is that we know who to protect, and the best way to do it is to create population-wide immunity as fast as possible. In doing so, we will not overwhelm the hospitals. We will not destroy the NHS – or any other health service around the world. So long as this disease does not rampage through the elderly population again.
For those who say, we must wait for a vaccine. I would say that you could be right to do so, one may appear. However, if you are not right, if problems emerge in development or rollout, what do we do. Lockdown forever? Keep the elderly apart from the rest of society, forever?
I would also say that we cannot plan on the basis that this ‘vaccine’ saviour of humanity may appear. We can only plan on the basis of what we know, what we have got right now. What we have got is a virus that is, for the vast majority of the population is, relatively benign. The majority of people who test positive are not even aware they have been infected.
Yes, of course, if we let COVID19 fly free in those under seventy, there will be deaths. How many? That is very difficult to say. John Ioannidis, a professor and researcher that I rate very highly, attempted to calculate the Infection Fatality Rate in the under seventy population. In July he put it at 0.04%. So, I will go with his figure.
0.04% is four in ten thousand. Which may not sound a lot to some. However, in the UK, we have sixty-seven million people, of whom fifty-six million are under age seventy. So, four in ten thousand fatalities would result in twenty-two thousand four hundred deaths. I agree that is a lot, but this figure comes in far too high, for a number of reasons.
First, it is estimated that we would need 80% of population to be infected, to create population wide immunity. So, we can immediately reduce twenty-two thousand four hundred to eighteen thousand. Still too many? Well we would, of course, shield people with underlying diseases such as type II diabetes and cancer and heart disease.
If the Centers for Disease Control and Prevention (CDC) figures are correct, ninety-four per cent of those who die of COVID19 have other serious underlying conditions. So, if we also protect those under seventy, who have serious underlying condition, the eighteen thousand figure reduces to one thousand and eighty.
Which means that it may be possible to achieve population wide immunity at a (maximum) cost of just over one thousand deaths, from COVID19, Probably not even that, as we do now know far better how to treat it than we did at the start. We could also do this by the end of the year – by the latest. You still think one thousand deaths is too many. Well, consider the alternative.
Let us look at just one condition, cancer. Due to the actions taken to reduce deaths from COVID19, there has been a serious delay in cancer diagnosis. Here from the Lancet:
‘Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer.’
The authors estimated the years of life lost from delayed cancer diagnosis and treatment will be in the region of 59,204 – 63,229. A year of life lost is not the same outcome as a life lost dying from COVID. However, sixty thousand years of life lost is significantly greater than one thousand COVID19 deaths, and the longer we go on, the greater this number becomes.
This, remember, is just one condition. The ONS estimated that lockdown has, so far, caused sixteen thousand excess deaths due to such things as people not attending hospital with heart attacks and strokes, and suchlike. I want to emphasize this is not my figure, it comes from SAGE 11.
I don’t think I can make the point forcefully enough that we are not playing a zero-sum game here, whereby every COVID life saved is a life saved, that would otherwise be lost. Lockdown itself, kills people, in their thousands and thousands. Their tens of thousands. More than COVID19 itself, in total? Some people think so, including me.
I say this because ONS further estimated that, in England alone, the economic recession itself will lead to around 17,000 excess deaths per year, for several years. Add that to the sixteen thousand this year, add that to the cancer lives lost…
‘This (estimated recession) produces an increase in deaths of between 1.2% and 6.8% in England as a result of the negative economic impact from COVID-19 and associated NPIs (actions that are taken to prevent the disease i.e. lockdown), with a central estimate of 3.1%. This is between 6,800 and 38,300 additional deaths per year, with a central estimate of 17,400 per year.’
The other point to bear in mind is that, if we shield the elderly and vulnerable, and create population immunity, we are also protecting millions of people who would have a far greater risk of dying if they became infected.
Using an infection fatality rate of one per cent in the over seventies [it is probably higher than that] we have twelve million people over seventy in the UK. If eighty per cent got infected, this could result in nine hundred and sixty thousand deaths. That would certainly overwhelm the health service.
So, I would ask people to turn their thinking around on COVID19. We have it within our power, right now, to get rid of COVID19 by the end of the year. Will this get rid of it forever – who knows – it may return in the winter. If not this winter, next winter?
If we open up society there will be a cost, there will be deaths, that is inarguable. However, I believe that we will save far more lives by letting this disease spread in the younger, healthy population. We will save both children and adults, and we can return to normal life.
Therefore, the proposal is simple. Work out who is most at risk, work out how to keep them shielded, then encourage everyone else to get out there and live their lives as before. [General Practitioners have already been asked to create lists of their patients who are most vulnerable, so most of this work has been done]. Once we have the infection rates sufficiently high to block viral spread, the entire population, including the elderly and vulnerable, can be released to live their lives as before.
The alternative is to wait, in hope, for a vaccine. One that is almost certainly not going to get here before winter arrives in the Northern Hemisphere. By which time further irreparable harm will have been done, and thousands more lives will have been lost, unnecessarily.