“Disobedience, in the eyes of any one who has read history, is man’s original virtue.”
― Oscar Wilde, The Soul of Man under Socialism
Cast somewhere in the indeterminate space between a cheery travel rep and Peter Kay’s building society teller, a sketch of Liverpool’s here-to-help Director of Public Heath Matt Ashton greets you on recent Liverpool Express blog post. In the background, the skies are blue, and there appear to be some stylised palm trees planted on sand dunes, but they might also be renditions of a Liverpudlian sky mark. The imagery is of blokeish affability, and as the blog is about health matters, one expects perhaps some gentle nudging to make sure you get your five a day, or stay safe when out in the sun. Nothing could be further from the truth. The post is instead a sabre rattling blood curdling Lord Kitchener styled “…your city needs you…” appeal, to Liverpudlians. Liverpudlians, the posts says, your city needs you to get tested for covid.
The first five paragraphs set out the grim statistics and consequences for Liverpool from the pandemic, setting the stage for what is to come: a Hotel California on a Merseyside fantasy world in which you can check in any time you like, but you can never leave. For here is the UK’s first mass covid screening pilot, not imposed on Liverpool by a high handed Westminster government, but invited in by Liverpool’s city council. For good measure, the same spirit of inclusive hospitality was extended to the British Army, who were also invited in, presumably to help with the catering.
That the pilot has more holes in it than one of Al Capone’s victims should come as no surprise, given the haste with which it has been launched. Matt Ashton, though now in Public Health, has a backstory that starts in economics, and travels through banking and the Inland Revenue, before ending up in Public Health, so it is perhaps not surprising that some of the medical niceties of mass screening have been rather glossed over. The quality of the screening test — always central to any screening programme — has only been hastily evaluated in clinical settings, in very few patients, with only the briefest of barely adequate published reports on the findings. And yet, the way Matt tells it, the test, which tests for viral antigen, can detect infectiousness, which it can’t: it’s the same old finding a broken needle in a haystack doesn’t mean you can say your haystack is a sewing machine thing, all over again.
Because the test was only briefly evaluated in quasi-clinical settings with symptomatic patients, where the prevalence of SARS-CoV-2 antigen was set high (between 25%, 75/295 from the IFU and this Chinese in English report of what appears to be the same trial, and 46% (60/131), from the mysterious unpublished Porton Down trial) , the results cannot be extrapolated to testing asymptomatic people in community settings, where the prevalence is an order of magnitude or two lower (around 2.2% in the North West, latest ONS figures). These significant differences in prevalence matter, because as prevalence falls, false positives increase, as the proportion of true negatives available to be incorrectly classified as positives rises. If you are doing mass screening, even a very small false positive rate can turn very quickly into a large number.
This flaw — over-confident deployment of a test in the field after trivial validation in small highly polarised trial — is a basic clinical error. What may happen in a specialised setting in a lab rarely if ever translates smoothly into real world experience. The recent Manchester screening pilot, for example, used a similar rapid test, based on LAMP technology, which claimed, based on lab tests, a sensitivity ranging from 55-96% (depending on viral load) and a specificity of 100%. In the field, the test achieved a sensitivity of only 46.7%, far below its claimed sensitivity. More than half (53.3%) of all true cases were missed, potentially infectious individuals wrongly told they were not infectious.
Liverpool’s mass screening is billed as a pilot, but as far as can be told — precious little has been published about the pilot’s protocols and procedures — the pilot is not about evaluating the clinical performance (sensitivity and specificity) of the Innova lateral flow test in use. That would require large numbers of Innova tested Liverpudlians to undergo an extra ‘gold standard’ test, the far from perfect PCR test, which isn’t happening. Instead, the pilot appears to be firstly, and most obviously, a logistical pilot: muster some soldiers and see what they can do; but it also appears to be a political pilot: can regular rapid mass testing, and all that follows from it, be made politically acceptable?
This is the point at which we get on the road to passport hell. About half way down Ashton’s post is this oblique reference to what lies further down the road: “In addition, people who test negative may be afforded more flexibility to carry on with their day to day life. We are exploring with government what this could look like”. Tie this in with Innova (IMG)’s ‘Our Story‘, and it becomes very clear what IMG’s Mr Huang and his buddies have in mind: nothing short of a health passport ecosystem; and Ashton is already ‘exploring with government what this could look like’. For a rather less benign view of ‘what this could look like’, consider this terrifying account of what is already happening in China, and that the company of ‘Infinite Possibilities’ behind the technology is already here in the UK, conveniently enough for Ashton, just down the road in Manchester.
Oppression doesn’t always arrive on the heel of a jackboot. Sometimes the oppressors seduce, by bold offers. Ashton’s post is sprinkled with just such offers: “save the lives of people you know”, “get us back to a new normal more quickly” (we’ll put aside the semantic nonsense of getting back to something new) and, perhaps most appealing of all, “a Christmas where we could do more social mixing and more of the things that we all enjoy”. But make no mistake: these offers are the appealing outer colours of a Trojan Horse that bears a payload of increased state surveillance, all implemented through a digital health passport ecosystem. Perhaps — should the state smile on you —more flexibility for those who test negative, but of course that means less flexibility for those who test positive, or ‘presumed positives’, those who refuse to be tested.
One could go on about the flaws. For instance, there are plans to extend the mass screening to schools. Putting aside ethical questions of informed consent, how many of the parents of those pupils who test positive will self-isolate? Hatt Mancock may have just announced Liverpool style testing will be extended to 67 regions, but so far, at the latest count, only 23,170 self-selected Liverpudlians have been tested, and of those, only 0.7% tested positive, which is itself intriguing, given the current ONS prevalence estimate of 2.2% for the North West. Could the real world sensitivity of the Innova test, like the Manchester test, also be less than 50%, such that we should be gas-lighting the green-lights?
Answers may or may not forthcoming, but in the meantime we could do worse than remind ourselves of Orwell and Wilde’s words. If we extend working class to include, as many do, all those who labour for a living and are paid in wages, then large swathes of Liverpudlians face a thousand influences constantly pressing them down into a passive role, where they do not act, but are instead acted upon, by the well intentioned but ultimately malign forces of misguided authority. But there is another option: rather than obediently track along the road to passport hell, heed Wilde’s rail against the sentimental dole, which, Wilde notes, usually comes with impertinent tyranny, and recognise instead the pure virtue of disobedience.