Things are looking up; in that, we are reopening and with jabs rolling out faster than before what could possibly go wrong… Famous last words!
Quite a lot can go wrong actually… especially when we are reopening almost as mindlessly as we did at Christmas. Although I’m glad we’re unlocking, I am concerned with the lack of a pragmatic strategy meaning, we could end up locking down again. Sure this time we have vaccines however not everyone is vaccinated yet and the June target of 80% in receipt of jab one, still doesn’t seem achievable. Although the high-risk people are pretty much complete we know the vaccine isn’t a cure and still allows contraction and spread. Hospital numbers may stay low, but what happens if the vaccines fail? By fail, I mean if a new variant arrives which is resistant to the existing vaccines or if case numbers continue to rise even with the jab, is there a point where the government will say ‘cases don't matter any more, only hospitalisation numbers’.
Let's assume that the light at the end of the tunnel is an oncoming train; how do we avoid another lockdown? First and foremost, we look to the countries that avoid lockdowns. We can learn a lot from South Korea. Then there were other countries (like Austria) who did have a ‘lockdown’ but not for as long or as strict as we did. They managed the virus with a degree of pragmatism towards keeping things as close to normal as possible.
South Korea stands out as having one of the most robust efforts to manage the virus without placing its citizens under house arrest. Although its highest level included a stay at home order, the crisis never reached that critical point and therefore never lockdown. South Korea learned a very hard lesson from the MERs crisis back in 2015 and in doing so invested significantly in their hospitals, having a bed capacity of just over 12 per 1,000 persons. But where South Korea excelled was in its detection and containment strategies and here we can learn to allot.
Testing, testing and more testing… testing and screening is the critical backbone to managing any contagion. If you look at the countries that handled the crisis the best, they invested significantly in screening and testing of patients for the virus, identifying spread patterns and infection among exposed persons aiming to catch cases before they had the chance to infect others. There is a distinction between testing and screening, the two aren’t the same and this is key to understanding how each work in tandem to managing a contagion.
Screenings can include testing, prior to symptoms to check for the presence of a disease in order to get ahead of a potential infection. However, screening sometimes doesn’t include testing instead (in the case of COVID-19) opting for a combination of questions and temperature checks. Temperature checks are the subject of debate, with some scientist including Dr Fauci (CMA to POTUS) describing them as “notoriously inaccurate.” Temperature checks work on the basis of detecting a potential fever that may not be present in asymptomatic people, who we have already established can spread the virus. However non-testing screenings can be of some use particularly in situations with limited resources. For example in Augusta Health in Virginia USA, even members of the same family were treated differently in terms of screening which included a test for some but for others questionnaires to determine symptoms, travel history and exposure. However, an ideal scenario is to have an actual test for COVID-19 to ensure the presence (or lack of) of the virus.
Testing is a diagnostic of a disease present in the body. The three main testing methods for COVID-19 are Nucleic acid tests (PCR) which test for the presence of viral RNA. An antigen test that detects the presence of a surface protein and an antibody test which as the name suggests test for the presence of antibodies. In addition, there is a separate ‘whole-genome sequencing’ test that identifies the specific variant present. Finally a rapid ‘Gargle and Spit’ test (G&S) using saliva and a mouthwash. All have their pros and cons and are not 100% guaranteed for example both the G&S, and Antigen tests can be achieved in the absence of a laboratory offering results more or less instantly for the G&S or within 15 minutes for antigen. The G&S has the added benefit of being the least invasive using mouthwash instead of probing the nose with a stick. Although the G&S is reported to be 95% effective, its antigen tests would be regarded as more accurate, equally PCR test more accurate on top of that. However G&S, for example, could offer more on-demand testing meaning in theory one could test at home before going to a house party, event or meeting friends or could be deployed at places where groups gather like bars, clubs and theatres to ensure people coming in have no obvious symptoms.
South Korea’s testing capacity achieved 110,000 daily tests by November, which demonstrates the degree of testing required for an effective management strategy. They set up 600 screening centres in strategic locations and this included 48 drive-thru centres which collected 3 times as many samples as the regular ones. They also established phone booth style stations which ensured workers were not in direct contact with patients.
Austria appears to be a leader in on-demand testing in Europe to enable normality to prevail during a contagion crisis. Earlier this year they launched Rapid Antigen testing which included free antigen testing to residents of Vienna, through clinics and drive-throughs. A test is valid for 24 hours. Negative testing gives you the peace of mind needed to go about your day, while a positive test will subsequently lead to a PCR test. Should it be positive, one must follow the standard positive tested guidelines and restrict movements. Antigen testing is not a substitute for PCR testing, but it means that we could in theory undergo regular, on-demand testing for free (even at home) before attending large gatherings, events, work, restaurants etc. But in late April they took an additional step offering a free gargling PCR test kit or “PCR Belt” for home testing. A game-changer because, unlike other gargle tests, this technologically driven approach is PCR level testing. The user gargles in front of their phone’s camera using an App. The test is sent via logistic operator Bipa and the results are received later that evening if submitted before 9 AM. A certificate with a photo and result is returned.
COVID-19 Tracking Apps
Ireland is among several other countries to introduce a COVID Tracking app to help trace contacts of COVID-19. Launched in July 2020 it utilises Bluetooth technology in a users smartphone to determine who they’ve been in contact with. The technological infrastructure was developed by Apple and Google in a hastily collaborated effort last year to building an anonymous tracking network of smartphones pinging off each other when nearby. Apple is a privacy-centric company and explains in detail their “privacy-preserving” focus behind the framework in a publication on their website.
The framework facilitates developers in building apps that can utilise the framework hardware on each device, much like how Instagram uses a phone's camera. This means however that regardless of Apple or Google’s efforts in hardware, the apps themselves controls and processes a certain degree of user data out of reach and separate from Apple/Google. Apple does, however, keep close control over apps available in its AppStore so they have a greater degree of influence over what an app is capable of doing than Google would through its Google Play store.
Interestingly a Trinity College report reveals the extent to how much personal data is been shared between Android users and Google servers describing it as such; “Level of intrusiveness seems incompatible with a recommendation for population-wide usage.” It's important to note the report distinguishes the two infrastructures (The Apple/Google Framework known as GAEN and the individual health apps) The report finds that most of the health apps themselves; "are generally well behaved from a privacy point…” noting that the privacy of the Irish app (Among the Polish, Danish and Latvian apps) “could be improved”. The issue is specifically with the GAEN framework on Google’s side. IP address, devices IMEI number, serial number, Sim serial number, phone number, Wifi Mac address and users email, among “fine-grained data” is shared between the Google Play store (The app’s end) and Google servers every 20 minutes. Regardless of who's responsible and what is done with the data, this processing of data tarnishes the reputation of such an app among users in a time where we are quickly learning the spine-tingling size of our data footprint and how that information can be used against us.
The app's effectiveness can also be brought into question. On April 7th 2021 Corks’ EchoLive.ie reported stats from the HSE confirming 2.2 Million downloads of the app with 1.5 million active users who were issued 30,000 alerts to date. Despite this, the Echo continue to report how one Cork-based HSE public health specialist didn’t find the app useful. She stated that the team in Cork/Kerry were not aware of a single case detected by the app, and is quoted saying the only case involving the app was already identified through normal contact tracing.
The concept is good but the key to its success is adaption. As one study calls it; “a lack of app adoption fails to achieve ‘digital herd immunity’ ” They believe tracing apps can be successful in identifying and following up on cases but acknowledge “success stories of mobile apps are scarce” in many countries because of “a systematic lack of adoption.” So the take away; the more people who download and use it, the better the data and ultimately effectiveness to achieve the goal. But adaption is hampered when people feel their privacy is compromised. There are several reports on this topic, one such report by International Law Firm Foley & Lardner discusses a broad spectrum of risk and implications including centralised vs decentralised storage and sharing, the scope of the data collected and the transparency all play into the difficulties of the apps adaption. The article believes it was a lack of transparency that resulted in ‘the final nail in the coffin’ for the app in Norway. They conclude that the apps are a double edge sword in managing COVID, in that the data reduces community venerability from the virus but increase vulnerability to privacy violations.
The solution seems to be having an app and infrastructure that collects the least amount of data ideally fully anonymously, data sharing limited and the greatest of transparency about what data is been collected, stored and how it is used. There needs to be an easy to re-instal solution to one account should a device be wiped or replaced, otherwise the service is at the mercy of a user activity re-downloading for the second time in the longer term lifecycle of the programme. Finally, there needs to be an understanding that some people will just not download the app, therefore an alternative may need to be offered to not exacerbate a sceptical population but incentivising download.
One incentive could be to merge the ‘check-in’ requirement at bars and restaurants which means instead of handing over a name and number to a stranger at these venues the app itself does the heavy lifting. We already introduced a system of check-ins in Ireland for certain venues, whereby one member of a group provides a name and number so that the restaurant could contact them should an outbreak occur. This strategy helps increase the tracing of clusters and cases, but merging this data with tracking app data would only strengthen the overall collection of data. In terms of incentives for users to download the app, built into the application could be a way of sharing a contact (anonymously) without having to hand over a name and number in the venue. South Korea took the approach of a digital check-in system using their KI-Pass system. Patrons were required to check in by generating and scanning a QR code. The codes did however collect actual personal data, but a properly setup system could again do this more efficiently and anonymously. Once concept from Korean startup firm SwlDch explains their simplified approach above.
All this data can not only inform individuals, it can also form the basis of a smart city database like that used in Seoul to allow policymakers and authorises monitor COVID spread and react accordingly. By identifying potential sooner, gives infected people less time to develop the virus and pass it on, thus ultimately contain the spread of the disease. The apps already discussed can be achieved successfully whilst also retaining the full anonymity of the user. Developers just need to make privacy the primary component in the design and be fully transparent with their users.
One could argue ‘having’ to carry around your device for tracing is edging closer to a vaccine passport-like scenario. However, the app isn’t discriminating against people based upon its data, it's only warning of potential contact and recommending following up with a PCR or antigen test and only then would someone be required to self-isolate in accordance with health guidance… But this wouldn’t be identifying you as an infected person and that data used against you. Once the data is only held for a minimum period of say 14 days then the data can only be used to facilitate COVID monitoring and not any purpose beyond this.
Smart City Database
Continuing with South Korea’s model, they took their data collection a little further which edges well into the parameters of surveillance… Seoul utilises cellular data, credit card data and CCTV on an individual level combining facial recognition and AI to identify a path of movement of people who test positive for COVID. One keynote to highlight about the South Korea model is that it's built on technology that is applied beyond just monitoring covid. It forms part of a Smart City Datahub, which is an accumulation and analysis of urban patterns used to flag traffic accidents and crime. When combined with “in-depth epidemiological investigations” (evaluations from patients interviews) this programme can reduce the contract tracing process from potently days to 10 minutes.
The level of data been processed goes far beyond the realms that are possible within a parameter that retains anonymity so privacy infringements are the biggest challenge to the implementation of any such system here, however one could argue that in times of crisis would a compromise to privacy be the lesser of two evils when comparing lockdowns and been forced to take primitive vaccines are the alternative?
The reality is our government are unlike to give us that choice… they will ultimately use both if they could and the risk of having this system utilised even outside emergency times is a highly probable scenario.
Without a doubt, a properly functioning hospital system is critical in managing a pandemic. Unfortunately, Ireland doesn’t have one. But it's not from a lack of funding. Following on from a podcast by David Mc Williams a few weeks ago, I decided to do my research on this. According to an OECD report, looking at 2019 figures, at €4,440 ($5276) per capita, Ireland is the 13th highest spender per capita out of 46 countries listed and 9th in a 27 member state Eu. Yet our bed capacity is 22nd place out of a 27 member EU according to a Eurostat 2018 report at almost 279 beds per 100,000 habitants. Our ICU capacity is half compared to Europe, according to a leading expert in a 2020 Irish Examiner article. So what are we spending our money on? Perhaps the cost of doing medicine? There needs to be a radical overhaul of the use of funding by the HSE to better manage the capital it receives.
We mentioned earlier the phone booth setup for screening in South Korea… By enabling systems of screening that protected the workers ensures those who are most inc contact with the virus (and in indeed others) are protected from exposure. One question I’ve always wondering was why bio-hazardous suits were not used. I can understand that they might not be the easiest things to work in but considering the degree of risk posed by having hospital staff exposed to the virus to subsequently leave the hospitals, go home to families or shop for food, isn’t this an obvious leak in the containment strategy?
Designated covid facilities (outside hospitals) could be set up to ensure hospital capacity isn’t compromised or better still to treat covid patients outside the hospitals entirely which would enable other services to continue unaffected. Although ICU beds may play a critical role in some cases… one option might be to have those as last resort, while treating mild or less chronic cases in purpose managed facilities. South Korea took a similar approach in that purpose facilities were established to allow patients to recover and isolate themselves away from households where uninfected family members reside and home isolation isn’t practical. It also serves as a place to manage clinically stable patients not requiring inpatient treatments. Symptomatic patients were categorised into three groups mild, moderate, or severe/critical. The former was sent to treatment centres outside of hospitals while the moderate sent to community hospitals, while the severe/critical attended ICU ready hospitals. Negative pressure isolation rooms were set up.
The mask has become the embodiment of COVID-19 and the focus point of perhaps the longest-running debate and controversy around the pandemic. It is the bedrock to a basic social distance and hygiene strategy but also entry-level protest. For most of us masks are an inconvenience, particularly if you wear glasses and at the very least is another ‘thing’ to remember when you are leaving your house… but for others, it's the catalyst for outright resistance. The mask got off to a bad start from the beginning with policymakers and health authorises including the WHO only recommending mask-wearing by those sick or showing symptoms or those working with sick patients, then suddenly almost overnight the advise change-making masks mandatory for everyone. But it’s not just fringe groups and outliers with this view. Denmark has discouraged mask-wearing among healthy people stating; “[mask wearing] can cause more harm than good” because people become complacent or masks become “a vector for the virus if mishandled.” Finland and Norway have a similar view in Europe alone. However, when you look at quotes like from Dr Mike Ryan of WHO during a Geneva press reported by CNN, it's easy to understand why some are sceptical;
“There is no specific evidence to suggest that the wearing of masks by the mass population has any potential benefit. There's some evidence to suggest the opposite in the misuse of wearing a mask properly or fitting it properly”
So how did we get from; “There is no specific evidence to “ [masks been] the most powerful public health tool”?
Mask wearing has become a cultural trait of many Asian countries, so it's easy to assume there must be some validity to them considering they’ve been using them for years, right?
Well not exactly… several reports including one from Quartz state that surgical masks (we’re are accustomed to) provide ‘minimal protection from environmental viruses’ and that the primary use of the mask isn’t for protective purposes. That is a secondary reason.
BBC have a detailed report on why Asian countries (among others) use masks. Stating for some it “in the spirit of solidarity” holding an assumption that even healthy people could be a carrier. Openly coughing and sneezing in public is impolite according to some East Asian countries. The WHO’s stance on mask-wearing at least as of December 2020 is that
“use of a mask alone is not sufficient to provide an adequate level of protection against COVID-19” but “Masks should be used as part of a comprehensive strategy”
This stance seems to be consistent with the growing number of research in the area. But also indicate that the growing number of healthy people wearing masks is causing a dearth of supply for those in critical need. Mandatory policies for everyone can have consequences on the supply of health service with a limited supply of PPE. Other research has highlighted that regions where masks are restricted to only the sick, can result in those who are sick been targeted or discriminated against this universal mask-wearing offers protection to those who need it. Some countries insisted on specific masks to be worn instead of just disposable masks and face coverings because the latter two offer less adequate protection according to some studies. Austria for example insisted on FFP2 Medical-Grade, but a lot of discussion and study references the N95 respirators, particular for medical settings. A WHO funded studies conclude that masks could have a “large reduction in the risk of infection” but highlighted N95 masks or similar respirators had a “stronger association” with risk reduction compared to the surgical masks. Another study in the journal of Influenza and Other Respiratory Viruses concluded that there was “low certainty evidence” that medical masks offered the same protection as N95 and that N95 respirators should be preserved for “high risk” “aerosol-generating procedures” when in limited supply. This would conclude in my view that the higher graded masks are better than the disposable and that maybe in Ireland we should be a little fussier about the level of protection we put around our mouth and nose.
In the absence of medical-grade masks such as N95 or FFP2, recommendations resorted to face coverings. In Ireland, we only have a face-covering mandate, not a mask specific one. But growing research indicates that although this does prevent spread… disposable masks are more effective and therefore masks are a full spectrum ranging from cloth masks offering some level, but increasing with surgical masks and again increasing further with N95, FFP2 and higher. Some countries have demonstrated low mask-wearing and a well-contained virus. However, a WHO study reported by The Lancet found an 85% reduction in infection risk when a mask is worn. So it would appear that there is some merit to mask-wearing with focusing on the type of masks used.
Work from Home
Work from home plays a key role in reducing spread. It's an obvious reduction in unnecessary gatherings when you consider crowds on public transport during rush hour who then are bundled up for at least 8 hours in a potentially crowned building. Although many jobs just can’t be done remotely, studies are showing that a considerable percentage of the workforce can work from home. Forbes reported on two studies; one conducted by economists from the University of Chicago found 37% of US jobs could be achieved at home, while a Norwegian report found a similar figure 36% for Norway. The Irish Times reports that an EU study showed the 40% of the Irish workforce could work from home. RTE report that 80% of Irish people want to continue working from home either some or even all of a week. Of a study among 1,000 people 14% said they would like to work in the office only when required while 15% preferred to return to normal. The rest would prefer a hybrid return of two, three or four days per week.
The CSO reported that the average commute is 28.2 minutes. If you take office works alone, working five days a week work from home eliminates 4.7 hours of high risk overcrowded public transport and 39 hours of office contact. This is a significant reduction in potential contact that many people don’t want in the first place.
Reduced numbers in hospitality.
Its hard to denying that allot of research clearly shows indoor environments increase the risk of contraction, particularly in small, poorly ventilated settings. However shutting down venues and banning house visits is an extreme, intrusive and damaging knee jerk strategy, which only serves to drive people underground into unregulated environments like shebeens. A better approach is remain open for business but implement pragmatic and subjective steps to reducing the risk.
First off reduced capacity. That should take into account the size of the premise rather than a one shoe fits all approach. Determine the number of people per square meter that can practically be accommodated under social distancing measures. This may mean that some business will be forced to operate at an unfeasible capacity and in such circumstances may need to consider closing or charging a premium?
El Pais demonstrate the strategy incredibly well on their website with an example of a bar reduced in the capacity of 50% to 18 people (three staff and 15 patrons) Their simulation highlights that with no further action results in a potentially significant cluster of infections among other people, particular over the course of a few hours. By including masks reduces the risk significantly, but might not be practical where food or drink are consumed. The next strategy is ventilation. This has been regarded as the key to reducing overall risk. Having good ventilation and airflow could be the difference between a cluster event and little to no secondary contraction. However; this is a scenario where a patron was infectious. If there is screening such as an antigen test before entry, the infected patron may have been identified and restricted entry meaning the risk of spread didn’t exist in the first place. https://english.elpais.com/society/2020-10-28/a-room-a-bar-and-a-class-how-the-coronavirus-is-spread-through-the-air.html
This isn’t just theoretical, significant research that has been carried out with several pilots conducted across the world. One such research by the Trias i Pujol Hospital in Germany recently concluded findings on an experimental indoor rock concert which demonstrated that when managed correctly, concerts are not super spreader events. The experimental concert was conducted among 5,000 music fans at the Palau Sant Jordi indoor sporting arena in Barcelona. The concert itself which was performed by the Spanish Indie Pop band ‘Love of Lesbian’ didn’t require fans to social distance and like any concert could sing and dance. The only requirements on concertgoers were to wear an FFP2 mask and undertake an antigen test before entry. (Presenting a negative test from no older than 8 hours previous was also accepted) The screenings identified 6 people who tested positive for COVID-19 before entry and were unable to attend the event, reducing the total audience to 4994. The venue itself ensured correct ventilation and managed the Bar and toilets in line with COVID guidelines. The report by FLS concluded that;
[the event] "had no impact on the transmission of COVID-19 among the attendees.”
While Dr Josep Maria Llibre of Trias I Pujol hospital stated in their report “a live music concert in a covered enclosure with the correct measures and ventilation is a safe activity.” The concert took place on March 27th 2021 and fourteen days later analysed 4,592 (those who gave consent) attendee’s COVID tests which identified 6 mild or asymptomatic cases with no secondary transmission. Four of those are confirmed to have contracted the virus outside the event.
The experiment was a success in concluding that 5,000 people can be screened and can “guarantee a safe space.” The research did highlight further questions, such as how to implement this in smaller venues, particularly the antigen testing aspect, concluding that it is possible but at a “very high economical cost”
So to conclude… we can live reasonably normal lives even during a pandemic if proper management is made with a focus on prioritising living. We may have to compromise just a little on privacy to enjoy greater freedom during pandemics, however, with smart thinking quite a lot of the basics of data sharing could be achieved anonymously. Accompanied with social distancing measures data-driven approaches are proven to be a key ‘behind-the-scenes’ fight in detection and containment of the virus. But ultimately extensive testing and tracing are essential to staying ahead of spread.
The alternative which we’ve lived through for over a year now has devastating impacts on people and the economy. The economy serves a greater purpose than just profits so it's a cheap shot to play the ‘money vs lives’ card with this argument. Lockdowns are also an expensive failure because not only millions of borrowed money funding PUP and business stimuli, they also fund the policing of lockdown policies. All his money could be better placed in funding testing tracing and supporting vulnerable people who might need additional help should they decide to cocoon during the crisis, while vast sectors of the economy that keep the social world turning can continue to operate.
Finally, we need to have a frank ethical debate on the level of restrictions allowed and a line drawn as to how far our governments can balance freedom with security. It's one thing to restrict everyday life like schools, shops, venues and public places, but a scenario of criminalising people for leaving their home unless they can justify their reasons for been out is a step too far in my view. No government should have the power to place its citizens under house arrest, which is what our government (among many others) did. Japan for example has in their constitution explicit protections preventing such measures. When it comes to freedom of movement (like any freedoms) Governments place should be advisory at most with people ultimately taking reasonability for their own actions and not require a government to make it for them.
I want to finish up with two final notes which may form the basis for future Unravel discussions. The first is with vaccine passports. Claire Byrne Live on April 26 gave an interesting initial insight into the vaccine passport and its limitations. Concerningly, what I took away from the segment was that the vaccine isn’t going to get International travel back to normal any time soon because of the uncertainties around variants, while the vaccine passport may not be an ‘easy to roll out’ system at least on an international level.
There are a lot of kinks in the road to make it viable and certainly doesn’t seem to be something that might hit the ground running in the short term. There are so many questions to answer both around the vaccine itself and its accompanying passport. Both have serious impacts on fundamental rights, freedom and will completely transform society beyond COVID. The real issue around vaccination passports is cloaked in the hysteria of COVID. While arguing its necessary to end restrictions placed on us ‘because of COVID’… it's setting a prescient for future restrictions on freedoms when managing future crises and the dangers posed by a centralised system that tracks and makes available on-demand ones medical data and the precedent to allow authorities, institutions and corporates to determine what one can or can’t do based on that data.
The second point is our relationship with death and how it has radically changed in Ireland in the recent decades, to the point where any death has become an intolerance even if the patient is at end of life stages. It's human nature to try and save every life particularly loved ones, and its a difficult subject to suggest a limit to what measures should be done to save lives, however at state level blindly trying to save every life regardless of the cost and without limits pose an even greater threat to society.
There comes a time where governments will have to pull a lever on the trolly problem however unlike the thought experiment, in real life there is the added complexity of the trolly derailing if the lever isn't pulled in time.
To quote Martin Luther King Jr.
“There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because conscience tells him it is right.” In my view lockdown is the ‘safe’ ‘popular’ choice. I'm not saying lockdown is popular or safe but because justifying lockdown while hiding behind the ‘saving lives’ card is a safer position for policy makers to take than to take the riskier unpopular choice to ensure the bigger longer-term picture is protected.