April 27, 2020

The past week has been a tale of two epidemiologists. First up was Swedish professor Johan Giesecke, whose interview with UnHerd a week ago caused quite a stir. Disarmingly blunt, uninterested in percentage points, Giesecke brushed aside the coronavirus pandemic with words that electrified sceptics and horrified his detractors. “I don’t think you can stop it,” he said, “it’s like a tsunami sweeping across Europe.” The real death toll, he suggested, will be in the region of a severe influenza season — maybe double that at most — so we should do what we can to slow it so the health service can cope, but let it pass.

 

 

Then, this weekend, it was the turn of Professor Neil Ferguson to answer the Swede’s critique that his overly pessimistic forecasts had tilted the Government into Chinese-style dirigisme. He cut a very different figure — more cautious, more media-trained, lacking the charismatic heft of the Professor Emeritus but making up for it with precise deployment of the facts and figures. Much as he’d love to be proved wrong, he said, the UK fatality rate of Covid-19 is likely to be 0.8-0.9%, which means that even letting out only the young and healthy will lead to more than 100,000 deaths later this year. We need to prepare for a long fight, a new socially-distanced normal, potentially for years to come.

 

 

In theory, theirs is a purely scientific disagreement that boils down to Infection Fatality Ratios, seroprevalence assays, and R0 numbers — and one or other of them will eventually be proved right. But somehow I suspect there will always be enough controversy around how deaths are counted and the economic and health impacts of lockdown to defer that judgement indefinitely. It’s also quite possible that one of them could end up being right in spirit while wrong on the numbers.

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Alongside all the metrics, and the vital assessments of the human cost of different policies, where you stand on this wretched virus also comes down to attitude — your world view. Are you more Giesecke or Ferguson? The expert that most resonates is unlikely to be entirely down to your assessment of the science — more likely a complex combination of your politics, your own life experience, your attitude to risk and mortality and your relationship to authority. Perhaps each of us have elements of both instinct within us — but what do they really represent?

What they are not, despite the attempts of some social media voices to make it so, are good and evil. Clearly, both experts are highly accomplished scientists doing their best to understand a complex threat. Likewise, the wider debate around lockdown is not a contest between rational, good people who value life on the one hand and the cavalier and cynical who care only about economics or themselves on the other. If the do-gooder class try to push that narrative, they will simply lose the argument.

There is not even an in-principle disagreement about the sacredness of every human life, despite attempts to slur those in favour of a speedier timetable out of lockdown as “pro-death”. The principle that some level of increase in infection, and therefore more deaths, is tolerable for the wider good is not often said publicly but is already accepted on both sides of the argument. Denmark, the poster-nation for early and stringent lockdown, has now brought back junior schools alongside published modelling that showed what level of increased infection (and therefore deaths) they expected it to lead to. Nobody raised an eyebrow, because the education of children is so obviously a moral good. It’s really a question of where you fall on a spectrum: how much death would you tolerate, for which wider goods?

In UK policy terms, the ‘landing zone’ now lies in the space between these two experts. At the Giesecke end, we would define success simply in terms of ensuring the NHS is not overwhelmed — this means slowing the spread and protecting vulnerable people as much as practically possible but moving to lift lockdown measures and only reintroducing them if the health service is challenged. At the Ferguson end, we would attempt to keep the outbreak at such low levels that we can wage a long-term ‘test, track and trace’ suppression of the virus, with elements of social distancing to minimise transmission until a vaccine is found.

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The appeal of the first of these options is that it has a clear rationale and an end-point when the virus has passed and life can return to normal. But it suffers from seeming callous and is highly dependent on the quantum of deaths. If we have 100,000 additional Covid deaths within the year, as Professor Ferguson warned, but could get fully back to normal after that, would that be acceptable? At two people in every thousand, most people would then know somebody who died. What about only 20,000 more? Or 200,000?

The Ferguson end of things will likely be more attractive to politicians as, while sidestepping this difficult question, it carries with it a clearer sense of virtue and action. As Gov Cuomo of New York is now fond of saying, “we’re not going to accept the premise that human life is disposable.” There is a strong appeal to society pulling together to protect our most vulnerable, and we know from polls that the public continues to support the more cautious approach.

But it is dangerous because it has no clear measure of success, and no way out: if the goal is just to “keep transmission low”, how low is low enough? Any move away from total lockdown potentially takes you further from your goal, and back towards a relentless fear of cases starting to creep up once again.

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In the ‘Giesecke’ worldview, this would amount not to a victory but to a surrender. The world becomes a place of indefinite anxiety, with the constant threat of curtailment hovering over all that is best and most human in life — family get-togethers, religious worship, children playing, plans for the future, creative projects – it risks becoming a conscribed, smaller, more fearful world. At its most extreme, a long-term ‘suppression state’ really could start to feel like oppressive regimes of history, from the Puritans to the Communists, that misguidedly tried to remake the whole natural order in pursuit of a single definition of virtue. People who recoil from any move in this direction can hardly be dismissed, or called immoral.

Somewhere in between these two opposing instincts lies a wise way forward; a path has to be found between not just different assessments of the facts but different world views.

In between his careful words, I detected something of the idealist about Neil Ferguson — the younger of the two scientists was keen to break new ground and win a battle. “We’re in a horrible place, aren’t we,” I said, expecting him to agree, but he immediately countered that, on the contrary, the world has achieved what he never thought he would see in this century, and has collectively stopped a highly infectious respiratory virus in its tracks. The South Korean model offers hope for an unprecedented new technology-driven response to an epidemic. For an expert who has spent years looking at fatality rates and modelling outcomes this must feel like huge progress: the entire world united against a disease.

Meanwhile, somewhat ironically given the laser-targeted threat of this disease on the old and vulnerable, the Giesecke approach felt imbued with the more philosophical perspective of later life. He has seen many pandemics; we live in a world full of various threats and dangers, and we can’t stop everything to try to run from one new one. Young people must be allowed to do what young people do, and older people, without the luxury of unlimited years ahead of them, must be allowed to choose to go back to seeing their grandchildren and living a full life even knowing the risks.

Whether you’re more Giesecke or Ferguson, it’s time to stop pretending that our response to this threat is simply a scientific question, or even an easy moral choice between right and wrong. It’s a question of what sort of world we want to live in, and at what cost.

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