Now that Boris the Builder has failed in his attempts to achieve greatness, first as the New Churchill, and then as the Noo Roosevelt, one hardly dare contemplate who is next in line for emulation. Perhaps there will be clues – denied reports of the summary execution in the Rose Garden of the first minister to stop clapping in cabinet? Or maybe the BBC’s melodious Lorna Squawksberg will report that sources close to Number Ten have confirmed the Prame Miniature will soon make a progress announcement on tractor production? Or, Heaven forbid, that we hear leaks of alleged  Cummings’ mutterings, that a single death is a tragedy, fifty thousand is a statistic? Only time will tell which hapless figure from history will next be reduced to one whackamoled dimension, but of one thing we can be sure, the Minister for Metaphors and Clichés will bear down at warp speed to double up on levelling down.

Or maybe it was double down on levelling up. But frankly, who cares? As a fellow jobbing wordsmith and crafter of metaphors, Dr No feels duty bound to remind the Prime Minister that puddings can only take so many eggs. Yesterday’s speech, billed as the Next Big Thing for the Economy, sounded more like an over-excited teenager telling himself what he was going to do with his new moped. And as befits a man who sees the world through a letterbox, too many of the metaphors had to be shoehorned to fit, and some were just plain misfits. Take the ‘covid lightening flash’ that ‘brutally illuminated…the problems in our social care system’. It wasn’t a lightening flash, it was a lightening strike, and it didn’t just illuminate, it destroyed.

As is so often the way, the speech was most notable for what it didn’t say, for the elephant in the room. This of course was the implications of Leicester, and its new local lockdown. Leicester did get a mention — a paltry three times — but the wider  implications were only touched on most briefly, through yet another ill-fitting metaphor, that Leicester was a reminder that the virus was ‘still circling like a shark in the water’. Elementary biology is sufficient to remind us that the only thing the coronavirus and a shark have in common is the ability to do us harm. In every other respect, they are opposites.

What can we learn from Leicester? The first is that is appears to be city level repeat of our earlier national response. An outbreak got going, initial attempts at local containment failed, and, after an interval of time marked by a paucity of communication, lockdown was imposed, enforceable by law. Now the key thing here is that the local containment failed. If local containment fails with only a few dozen cases, if that* — daily and total case numbers for Leicester can be seen here (click on the map to get a display of data for the area), and downloaded here (big csv file), and it looks like the recent daily numbers of new cases are usually less than ten — then, sooner or later, all cities will be Leicester clones. Bear in mind that so far (as of 30th June) there have been only 312,654 confirmed cases in the UK out of a population of 66,796,807. That is a paltry 0.47% of the population, meaning the vast majority of us are still at risk of infection. Even if we say there are 10 cases in the community for every lab confirmed case, that still leaves 95% uninfected, and so vulnerable.

*Additional info added 1900 hours: it is now clear that the PHE data (quoted above, and also that supplied to Leicester until very recently) are only for Pillar 1 (hospital) testing, and omit Pillar 2 (community) testing. For the two week period 13th – 26th June, Pillar 1 testing revealed 80 news cases (avg 5/day, consistent with above assessment), while Pillar 1 and 2 testing revealed 944 cases (avg 67/day, a lot more but still not a huge number). It seems the Pillar 2 data were withheld because of some contractual balls-up with the private contractors doing the testing/counting…

These very low levels of exposure are not inconsistent with the latest ONS prevalence study, which suggests the current two week prevalence (people who currently have the disease) in England is around 0.09% (95% confidence interval (CI): 0.04% to 0.19%). The large-ish CI tells us the estimate isn’t very certain, which is not surprising given that the only real way of establishing the true number of total infections, past and present, is to do a large scale community based antibody and PCR testing, and that simply hasn’t happened yet. We can, by the way, safely ignore the bed-wetting higher estimates of total numbers infected as yet more fanciful numerology. However, during the 21st May episode of Hancock’s Half Hour, the SoS reported that a small scale antibody based survey suggested that, excluding London, ‘around 5% or higher in the rest of the country, have tested positive for coronavirus antibodies’. The bottom line remains, the vast majority of us have not yet been infected.

We can therefore assume that the Leicester spike and subsequent local lockdown is simply the first of many many more yet to come — unless we can do something to halt these spikes. At present, the options available to us are not encouraging.

The final solution, not Dr No hastily adds, in any reductio ad Hitlerum meaning of the phrase, is immunity, either naturally gained or through a vaccine. The low total number of people infected so far, and indeed the possibility that infection may not confer long-standing immunity, means that we are a long way from achieving so called natural herd immunity. A vaccine remains a possibility, a distinct one, but still no more yet than a possibility, with necessarily months if not years of delay before one becomes available.

The Communicable Disease Control option is local containment by rapid case control through testing and contact tracing, with quarantine as needed. This, on paper, and indeed in the eyes of the Independent SAGE group, is the logical option, but it is beset with problems. Testing, so that you know whether you have a case or not, is still too slow and too unreliable, and, as we have seen in Leicester, is hampered by poor centre to local communication. The national scheme — Dido’s cake — remains half baked, and her cherry remains no more than a glint in Matt Hancock’s eye.

Even worse, local public health departments, hollowed out by years of austerity, are unable to cope. CCDCs (consultants in communicable disease control), whose career defining moment may have been investigating a minor food poisoning outbreak a few years back at the local Chinese takeaway, lack the heft, clout and experience needed to take control. Put simply, without substantial investment, which needs government commitment, and training, which takes time, local case control through traditional public health methods is a non-starter, at least for now. That, if nothing else, is the lesson learnt from Leicester. Dr No adds the ‘at least for now’ caveat because there is an option to put in the money and training, but somehow he doesn’t see the government doing that any time soon.

Which leaves just two (given ‘do nothing’ is not an option) remaining options: local lockdowns, and intensive local shielding of the vulnerable. Time will tell, but Dr No has a hunch the local lockdown in Leicester will rapidly become a disaster, a doubling up on levelling down. Already hard hit local businesses will be (in the true sense of the word) decimated. The very local nature of the lockdown, with a hard boundary — take one step to the left or right and you are in or out of the lockdown — will make a mockery of policing, and that doesn’t bode well, because no policeman likes being made a mockery of, meaning a significant risk of heavy handed policing. The postcode lottery of who is in, and who is out, removes the ‘we are all in this together’ element of a national lockdown, so we can expect civic unrest, staring this coming weekend, if not before. Lastly, it suffers from the Achilles heel of all lockdowns: what is the exit strategy? All in all, it is not a good idea, and if Dr No is right, time will show it to have been a very bad idea.

Intensive local shielding of the vulnerable is on the other hand a perfectly viable option, all the more so having ‘learnt the lessons’ from the failure to protect so many of the vulnerable during the national lock down. The pre-requisites are already in place: we know who the vulnerable are, and we know how to protect them. It is as simple as avoiding exposure to the virus, and it really is that simple: carer testing, and exclusion of cases and other visitors with symptoms, combined with voluntary — the voluntary element is essential — extreme quarantine for the vulnerable, by which Dr No means no excursions into the outside world, and only very limited incursions by the outside world into the vulnerable person’s own little world. Yes, their will be cracks in the defences, and some will die before their time, but the numbers will be very very small — still tragedies all, but nowhere near a statistic.

Extreme quarantine of the vulnerable is harsh and cruel, and that is why it must always be voluntary, for those with mental capacity. Those without can be cared for, as usual, by the proper use of best interests. If a grandmother wants to attend the wedding of her daughter, that is her choice. Her doctors can tell her the risks, but never what to do, and that blasted interfering monstrosity of the state should limit itself to what it does best — doubling up on levelling down. Or was it doubling down on levelling up?                   

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  1. dr-no Reply

    Further addition at 2015 hours: It seems there may be more that a whiff of porkies about the Leicester affair. The focus of the post was on ways of dealing with local outbreaks, not the specifics of the Leicester case. After some more research on the specifics it seems there are two accounts: the Government says it did tell Leicester about the Pillar 2 cases a while back, and sent in extra testers, while Leicester (and Labour) say Leicester wasn’t told anything until around 48 hours ago. Both can’t be right. If the government did send in extra testers, then surely the local authorities would have noticed that, even if they were explicitly told why there were extra testers. Were the local authorities asleep? Or maybe the extra testers were invisible? This has all the hallmarks of a political spat…

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