Dr Liam Fox MP - Sunday Telegraph article - Making sense of coronavirus: Only with data will we know if right ethical calls were made
Writing in today's Sunday Telegraph (https://www.telegraph.co.uk/news/2020/04/04/making-sense-coronavirus-data-will-know-right-ethical-calls/) on 5th April 2019, Dr Fox wrote:
The handling of the Covid crisis sits at the interface between scientific data, political judgement and ethical decision making. Behind every statistic about case numbers or deaths there are families being devastated, friends lost, and loved ones gone forever.
For the public, the bombardment with information and advice can be confusing and sometimes overwhelming. This is of course exacerbated by fake news in social media. So how do we make sense about what we see and hear every day? What do we know about who is most and least at risk? This will be important when it comes to unwinding the lockdown. Is the Government overreacting to the crisis and putting our economy at risk unnecessarily? How will we dismantle the current restrictions on what will be an increasingly impatient public, and when? These are not academic questions. They affect the physical, mental and economic health of both individuals and our society as a whole.
We know from emerging medical data those who are at greatest risk if they contract the disease and this has enabled the NHS to send a letter out to those in the highest-risk group – for example, organ transplant recipients, those having immunotherapy or other continuing antibody treatments for cancer, and people with severe respiratory conditions. But the population is not just divided into high and low risk. It is more complex than that.
We know from experience in this and other countries that those who are elderly and have pre-existing conditions such as high blood pressure, diabetes or other cardiovascular disease are at greater risk, particularly if they have more than one condition at the same time. While they may not be in the most severely-affected category, they are at greater risk than the general population and more numerous than those in the highest-risk group. They need to take extra precautions. The general advice about avoiding contact, social distancing and simple hygiene is even more important if they are to remain safe.
At the next risk level we have the general population who are the key to protecting these vulnerable groups from the spread of the infection. This matters to even those at lesser risk as some of them may still end up in hospital, intensive care or on ventilation. Unnecessary exposure to the virus in this group could ultimately lead to a loss of capacity elsewhere meaning that those in high-risk groups could find themselves without the necessary support.
Part of our problem is a lack of data about how widespread the virus has actually become due to our lack of testing in the wider public who have no symptoms at all. Some studies in other countries have suggested that a high proportion of the population could have been exposed to the virus without developing symptoms, though they could still be spreading the virus to others.
Within the general population we also have a large subgroup - young people - where the severity of the disease tends to be milder, although it is crucial to point out that some of them might go on to develop serious and potentially fatal illness.
This lack of data makes it very difficult to answer the second question – has the Government overreacted to the situation and will our economy pay an unnecessarily high price?
This is a question that will only be possible to properly answer in retrospect. For the moment, the Government has quite rightly put the protection of lives and preserving the capacity of the NHS at the top of the agenda. They have leaned towards ethical decision making. They deserve credit for doing so. Sadly, but typically, many of those who are now claiming the Government has overreacted are the same people who were calling for even stricter restrictions only a few weeks ago.
One of the key pieces of data that will be crucial to answering the question is whether there is any excess number of deaths in this period compared to previous years. This number has natural variability due to things such as seasonal influenza outbreaks or excessively cold weather.
Wrong conclusions are wrongly drawn on small amounts of data, usually to justify a particular political argument. We know that the number of deaths in January 2020 (56,706) was higher than that of January 2019 (53,910) yet the figure for February 2020 (43,653) was actually lower than that for February 2019 (47,796). We will need to see figures over the coming months before we can get an adequate feel for the effect that coronavirus has had and we will need to take into account the fact that social distancing, isolation and better personal hygiene may have reduced the incidence of normal winter illnesses. There are anecdotal tales from a number of clinicians that they are seeing reduced rates of meningitis and influenza at the present time which might complicate the analysis.
In determining whether the scale of our reaction is appropriate we also need to look at other standardised and comparative data. For example, what is the death rate per 100,000 population of those who have died with coronavirus and how many are in the part of the population who might have been expected to die in the winter months in normal circumstances. In other words, how many have died with coronavirus and how many have died of coronavirus?
We also need to see the hospitalisation rate per 100,000 of those diagnosed with coronavirus and what proportion of those end up in ICU and how many of these end up on ventilators to determine how appropriately we have dealt with the surge. This in turn will tell us what sort of capacity we need to be able to regenerate quickly to deal with any future outbreak of this or similar pathogens.
All this data, telling us our risk groups stratified from the highest to the lowest, will be essential in unwinding the lockdown. We will have to be able to answer the question – how do we reduce the risk of infection in the population while lowering the costs to our economy? We will need to be able to return those at lowest risk back into our economy first and expanding it to other groups while protecting those who remain most vulnerable and minimising the risk of a second outbreak.
The political judgements and ethical decisions will still need to be made, but hopefully supported by much better objective data than we have had up till now.