[Posted 21 March, updated 26 March]
I have COVID-19. Or maybe I don’t. I’m really not sure, since the UK isn’t testing anyone who doesn’t require hospitalisation.
I’m on Day 5 or 6, I think. It began with a tight upper back and a slightly sore throat. Then there was a day of very minor fever and very swollen throat. Since then, the sore throat’s been persistent, and a cough has developed, first as a dry, upper respiratory cough but increasingly as a more mid-level, mucousy cough. And I have moderate fatigue.
In any other context, this would be an illness that might lead me to miss one day of work and perhaps make me operate at half-speed for a few more days. In any other context, the virus wouldn’t leave me particularly worried. Now, however, it’s left me in self-isolation. And, while I’m not really worried, I am worried about whether I should be worried.
So, my thoughts about COVID-19 as something that’s “out there” are entangled with my thoughts about the virus that is (or, maybe isn’t) “in here.” The scales intersect in a dizzying way.
Looking at COVID-19 from the outside, there are some important questions that get to the heart of how we think about (and manage) disease, risk, and probability, and how this all gets reflected in policy. Is the COVID-19 risk really qualitatively different from other viral infections? Even if the difference in risk is just quantitative, do we require qualitatively different responses in order to deal with this quantitatively different situation?
But I can’t separate these policy questions from some of the questions that I ask as I reflect on my own health. Given that I don’t have any special risk factors (at least so far as I know), is this virus that I’m hosting (even if it is COVID-19) only marginally more likely than any other virus to lead to something serious? But maybe that’s not the point. Regardless of what the virus may be or what my health is, should I be radically altering my behaviour in order to not infect others who are more vulnerable (don’t worry; I am)? And, anyway, how do I know that, although I’m 54, I don’t, at some level, have the body of a 70 year old?
So, again, I’m back to those nagging questions: Should I worry? And, if I’m not worried, should I worry about not being worried?
But the angst in my own response pales, I think, with the angst being wrought by the UK government’s response in its initial policy. It seemed almost designed to foment panicked frustration.
To be clear, I certainly could understand a government not wanting to admit the extent of the coronavirus problem. After all, admitting that one is trying to manage an epidemic likely would require acknowledging past failings and it probably also might suggest a need to take draconian measures that could lead to economic hardship and political unrest. No government wants to go down this road unless the alternative is seen as even worse (e.g. to be seen as weak, and thus illegitimate). I get that. And, conversely, I also could understand a government seizing upon the crisis as an opportunity to strengthen state institutions, close borders, clamp down on labour rights, and reduce (non-health-related) social safety nets. Perhaps the US government’s muddled response (first, Trump’s denial, and then his support for a corporate bail-out package) can be understood as a vacillation between these two reactions.
But then there’s the seemingly inscrutable case of the UK. The UK’s position of encouraging the infection rate to spread until we reached herd immunity has been criticised by numerous public health experts as bad policy. But the programme would also seem to be bad politics. After all, who wants to hear their government say, “It’s really bad, but we’re not going to do much about it, and we’ll sacrifice some of you along the way?” And it has taken the UK government exceptionally long to shift away from that position. Most new policies adopted over the past week (until last night’s at least) have been voluntary and are so riddled with exceptions that their impact would be muted. Even now, attempts to limit the disruption of normalcy continue. Just look at the long list of professions whose children are exempted from school closures, for instance; it seems likely that most schools will need to remain open even as they are “closed.” Indeed, the whole narrative of a radical shift in policy based on new data is fishy. As Lancet editor Richard Horton has pointed out, the findings of the Imperial College London modelling exercise that supposedly led the government to shift gears weren’t that different than those that were previously informing policy.
So, if the UK policy was bad (from both a policy and politics perspective) and if it remained bad for so long (and still, to a degree, continues), what’s driving it?
I’m always wary of explanations that point to the distinctive nature of a national culture. ‘Culture’ is way too messy a term to be an independent variable. That said, the “herd immunity” policy does seem to align particularly well with a very British mixture of collective fate (“we’re all in this together and we can get through it by sticking together and fighting the good fight”) and individual responsibility (“so if you don’t get through it it’s your own damned fault, because I’m taking efforts to protect myself”). I can’t completely shake off that explanation; it resonates in my head when I see Boris Johnson trying to channel his inner Churchill, and it also appeals to the British desire to be seen as just a little more stubborn than everyone else and therefore just a little more cunning (see: Brexit) . But I also don’t think it’s the whole story.
Another possibility, which some have suggested, is that it diverts attention from the public health failures brought about by historic underinvestment in health (and other public) infrastructure under neoliberal governments. Given that health systems are underresourced, it may well make sense to keep all but the most ill away from them so as to avoid straining them further beyond capacity. However this strategy, while perhaps a rational solution to a bad situation (albeit at the expense of good data gathering), diverts attention from the fact that this bad situation was in part a result of prior state policies.
Approaching this question from a different angle, though, what’s most intrigued me about the UK government’s response has been the way that its leaders (the Chief Medical Advisor and Chief Scientific Advisor, as well as the Prime Minister) have discussed the imminent development of “game-changing” scientific advances. I’m no medical expert, but it seems to me that there are three basic kinds of medical advances potentially on the horizon: A test for presence of the virus’ antibody (which would indicate a recovered individual); a drug to prevent the active replication of a virus or its ability to implant in cells (and cause subsequent illness) among infected individuals; and a vaccine to prevent uninfected individuals from contracting the virus at all. I am struck by how in the UK (and, so far as I can tell, only in the UK) official pronouncements place so much emphasis on development of a test to identify the presence of an antibody whilst relatively little attention is given to the potential for the other two pharmacological advances. [26 March update: This has continued, most recently with Public Health England’s announcement that a home-based pinprick test for antibodies will be available “within days“.] This emphasis on a test for identifying antibodies is odd because, from the perspective of an ill individual, or from that of one who fears getting ill, development of a vaccine to prevent illness or of a drug to limit its replication within a body would be much more valuable than development of a test that simply indicates whether one has previously been exposed to the virus.
One might argue that an antibody test would be very valuable because it could be used to compile data that could then be used to guide public health policy. However, if gathering data in order to target public policy were the UK’s primary concern, then why is the British government so nonchalant about testing individuals with presumed symptoms (like, for instance, me)?
So, that leaves me searching for other explanations. The cynical one is that Westminster may be aware that a British company is close to developing such a test, but that other countries lead in the race to develop a vaccine and a drug to inhibit replication. By defining the antibody test as the game-changing medical breakthrough, the UK would then be in a good position to hail itself as a world leader.
But I also wonder if this focus on progress toward development of an antibody test might be the hangover from a never-forgotten focus on developing herd immunity, notwithstanding the supposed abandonment of that goal. After all, if you’re trying to build herd immunity, then the percentage of individuals who have been infected in the past and are still alive is the most important thing. It’s the test that you need to reach your ultimate goal, and it pushes aside other goals such as developing the means to prevent infections (through a vaccine), or to prevent deaths from infections (through a replication inhibitor), or to identify who is infected now (through implementation of a widespread testing programme).
But why is herd immunity so important? Prime Minister Johnson gave the answer in the same press conference where he touted the ‘game-changing’ antibody test that was on the horizon:
“The great thing about having a test to see whether you’ve had it enough is suddenly a green light goes on above your head and you can go back to work in the safe and confident in the knowledge that you are most unlikely to get it again.
“So for an economic point of view, from a social point of view, it really could be a game-changer.
“You can really see the potential of that advance, which, as I say, is coming down the track.”
If the ‘game’ is to keep people healthy, then the impact of a test for the presence of an antibody is limited. However if the ‘game’ is to get Britain back to work, then indeed the test would be game-changing.
All of this strikes me in a particularly profound way because, in a week or so (presuming things don’t get worse), I will be feeling better and will be wondering which sub-herd I will be in: the 60 percent that will have “taken it on the chin” to make Great Britain ‘Great’ again, or the laggard 40 percent who will be protected by all those brave souls who sacrificed during the Great War on COVID (and, yes, also by that small percentage who will have made the supreme sacrifice so that the herd can remain strong and proud).
But I don’t want to end with snarky cynicism (although the World War analogies are easy to make), because the fact is that I will be eagerly waiting for that antibody test to be developed so that I can find out my status and whether my current ailment in COVID-19 or just a common flu. Personally, it would be useful for me to know whether I have developed immunity to COVID-19 and can ignore further warnings (although it’s not entirely clear that second infections are not possible) or whether I am still vulnerable. Or, put another way, I want to stop worrying about whether or not I should be worried.
At the same time, though, at a more macro-scale, this kind of knowledge would allow the herd to be divided, with different social control measures being applied whether or not one has tested seropositive. And here the analogy might be less to the Great War and more toward a dystopian science fiction novel, where two tribes – the immune and the vulnerable – live in fear of each other. Or perhaps it could be a Zombie film, with two opposed sides, each perpetually in danger of becoming the other through excessive contact, each working assiduously to reproduce their divisions, even as they continually interact.
In fact, maybe we could just be very British and call it class.
[26 March update: Thanks to those who have wished me well. I’m into day 12 now and am just about free of symptoms: still a bit of sore throat and a bit of residual weakness, but I’m almost back to normal.
Advice for those with similar symptoms: Paracetamol (or acetaminophen or Tylenol or whatever they call it where you live) worked incredibly well on my throat; I could really feel the pain increase when a dose was running out and it was time for a new tablet. Warm liquid, including gargling with warm salt water (thanks Louise Amoore for that tip) helped too.]