Say the Liberals Win, Then What

An article form The Atlantic by Elaine Godfrey

If Democrats manage to hold the House of Representatives and win back the Senate and the White House in November, the party will have full control of the federal government for the first time in 11 years. Police reform, climate change, and health care are all on their agenda. But before newly empowered Democrats get to any of that, they will very likely pass a relief package to address the coronavirus pandemic and the associated economic crisis. Then, they will aim to fundamentally change how voting and government work in the United States by expanding voting rights, reducing the influence of money in politics, strengthening ethics rules, and maybe even ending the Senate filibuster—reforms they hope will make America’s democracy work better and the rest of their agenda easier to carry out.

“If there is any political capital to be spent, the concerns over democracy reform take a front seat to everything in the agenda,” a senior aide to a progressive senator told me (the aide requested anonymity because he wasn’t authorized to speak on the record). It “would mean so much just in terms of building long-term power,” a senior aide to a progressive House Democrat added.

By starting with these reforms, Democrats are taking a risk: They’ll likely have only a short window of time in the majority to accomplish their most pressing agenda items. Prioritizing one item could mean sacrificing another—and failing to deliver on key issues.

But the Democratic lawmakers, staffers, and activists that I spoke with view government and voting reform as a kind of precursor to accomplishing any of their other policy goals. “The first attention will be to the economic implosion, but there are a group of [other] issues on people’s minds,” Senator Jeff Merkley of Oregon told me. “We are at that moment where we have to succeed now in restoring the integrity of the American vision.” Democrats have given these process changes, which they call “democracy reform,” top billing on their legislative docket before. The For the People Act, more commonly known as H.R. 1, was the first piece of legislation the Democratic-controlled House passed in 2019. It contained a grab bag of reforms: establishing automatic voter registration for all Americans, making Election Day a national holiday, ending partisan gerrymandering, requiring presidents to disclose their tax returns, and creating a public-financing system for federal campaigns. These reforms would make it easier for most Americans to vote. They’d also, Democrats hope, make it easier for Democrats to win elections.

The Democrats’ plan is informed by experience. The last time Democrats controlled both the White House and Congress, they—under the leadership of President Barack Obama—attempted, at least at first, to foster a good working relationship with Republicans. Yet, after weeks of negotiations, the 2009 stimulus bill received only three GOP votes in the Senate. Not a single Republican voted to pass the Affordable Care Act, after a year of negotiations and floor debate—despite the fact that the legislation was modeled, in part, on a Republican template, and GOP amendments had been accepted to the bill. Obama had hoped to reach a “grand bargain” with Republicans but instead became acquainted with what his aides came to call “the party of no.” Many Democrats believe those times offer a lesson: They need to fix the structural issues that have long given Republicans political power disproportionate to the number of votes the party wins.

Republicans, naturally, are deeply resistant to many of the proposals included in H.R. 1. They argue that the provisions amount to extreme government overreach, and that expanding voting access through mechanisms such as automatic registration will open America’s elections system up to voter fraud. Not a single Republican voted to support H.R. 1 in the House last year, and Senate Majority Leader Mitch McConnell has blocked it from coming to a vote on the Senate floor. “They’re trying to clothe this power grab with cliches about ‘restoring democracy’ … but their proposal is simply a naked attempt to change the rules of American politics to benefit one party,” he wrote in a Washington Post column.

With McConnell and House Republicans opposed to most of their priorities, Democrats will have to structure their agenda carefully—and move quickly. Some Democrats would prefer to take advantage of the increased appetite for health-care reform to pass Medicare for All or a public option in the first weeks of a Joe Biden presidency. Others see climate-change legislation as the first priority. But voting-rights expansion and campaign-finance reforms would likely be simpler and faster to pass, given that the framework already exists in H.R. 1, the Democrats I spoke with said. And everyone agreed that both health care and climate change could be addressed—at least to some extent—in an initial coronavirus-response package; Biden’s “Build Back Better” economic-recovery proposal already promises investment in clean energy sources.

By January 2021, America will likely still be experiencing the twin public-health and economic crises brought on by the coronavirus pandemic, and voters will likely have gone through a drawn-out and chaotic November election. Appetite for political reform will be high, Democrats argue. “Over four years, we’ve learned of weaknesses in our democracy,” Neera Tanden, the president of the Center for American Progress, a Washington-based liberal think tank, told me. “To move a progressive agenda, we need to restore faith in government.”

Another reason that many Democrats would like to prioritize H.R. 1: It’s one of the few issues that unites nearly all factions of the party, so it’s politically feasible. Every single House Democrat voted in favor of the bill. “There’s gonna be an element of, how can you show progressives that you’re in it to win it and willing to go big? There are some things on democracy reform that will really send that message and really do that,” said one aide to a centrist senator, who was not authorized to speak on the record. “Leadership knows that is an issue that would make the left very happy and allow the moderates to deliver on what they’ve promised,” Lanae Erickson, a senior president at the think-tank Third Way, told me.

Democrats believe their reform agenda could be a political winner. “Ending the culture of corruption in Washington” was the top issue for 75 percent of voters in swing districts in 2018, according to a poll from Greenberg Quinlan Rosner Research. That year, 72 percent of candidates on the House Democrats’ list of highly competitive races rejected donations from corporate political action committees, a pledge that became a litmus test during the campaign. That was up from just 6 percent in 2016, according to End Citizens United, a political action committee working to pass campaign-finance reform.

Before they can pass their “democracy reform,” though, Democrats have to decide exactly what that entails. Most progressives interpret the phrase to include not only expanding voting rights, but also establishing D.C. statehood and abolishing the Electoral College, two proposals that are still controversial among rank-and-file members. Public support for both ideas is mixed: More than 60 percent of U.S. adults oppose D.C. statehood, according to a recent Gallup poll, while a majority of Americans support amending the Constitution so the presidential candidate who wins the popular vote wins the election.

But far and away the most serious threat to the effectiveness of a Biden presidency and a Democratic House and Senate is the filibuster, the Senate rule that requires 60 senators, instead of a simple majority of 51, to move forward on most legislation. Even if Democrats win the Senate in November, they very likely won’t have 60 votes, meaning that Republicans could still block legislation from being debated. Progressives have long wanted to abolish the supermajority voting threshold, but the idea has begun to gain traction among other Democrats, too, in recent weeks. Perhaps, some Democrats argue, the filibuster is a natural place to launch their democracy-reform initiative: They can put forward a slew of policies strengthening ethics guidelines and expanding voting rights—including a bill that would restore the Voting Rights Act of 1965—and dare Republicans to vote against it. (The VRA had strong bipartisan support until the mid-2000s.) “It’s a pretty easy argument to make,” the aide to the centrist senator told me. “Democrats would be happy to be like, Look at these fuckin’ guys! They still want to make it difficult for people of color to vote!”

Progressives are enthusiastic about that plan. “If I had to guess how it’s going to happen, it’s going to be, If we can’t pass the VRA, we’re going to get rid of the filibuster,” Adam Green, the co-founder of the Progressive Change Campaign Committee, told me. “Starting with H.R. 1 is a good idea,” Representative Ro Khanna of California told me. “The filibuster could come right next.”

Then again, Democrats might not have any of these options in January. Trump could win the election; Republicans could hold the Senate or even win control of the House. The Democrats could sweep, but have something else at top of mind. Or, some of my Hill sources suggested, Biden may want to start off his first term by pursuing legislation that is more amenable to Republicans, though none of the aides I spoke with could identify what that unifying project might be. When asked about Biden’s own legislative priorities, a campaign spokesperson responded that his No. 1 goal will be “repairing and rebuilding from the economic ruin and public-health crisis caused by Donald Trump’s utter failure to fulfill his basic duty as president: protect America.”

Even if they win full control, though, Democrats won’t have a lot of time. As my colleague Ronald Brownstein noted recently, “the last four times a president—of either party—went into a midterm with unified control, voters have revoked it. … No party has controlled all the levers of government for more than four consecutive years since 1968.” And a President Biden and an incoming Democratic Congress will be facing a mountain of tasks. There will almost certainly be early battles over government funding and coronavirus-response packages.

If Democrats find themselves in the majority again for the first time in more than a decade, though, they are determined not to squander the opportunity. In his July eulogy for Representative John Lewis, Obama implored lawmakers to quickly make changes that protect and expand the right to vote—not for partisan advantage, he insisted, but in an effort to form a more perfect union. Republicans remain skeptical. But Democrats were listening.

Who should be vaccinated first

An article from THePrint.in by Manjeera Gowravaram

Why the old, comorbid, children & those who WFH shouldn’t be first in line for Covid vaccine India must vaccinate healthcare and essential workers first to ensure no breakdown in national systems. This will also help revive the struggling economy.

Many Covid-19 vaccine candidates have reached phase 3 clinical trials, and the world is hopeful that one or more candidates will clear the regulatory demands and be authorised for commercial deployment in the near future.

While the wait remains, India must look ahead and start deploying strategies for prioritisation and distribution of the vaccine once it becomes ready. Although it would be ideal to immunise every individual as soon as the vaccine is approved, practically it won’t be feasible.

The production capacity will be the rate-limiting step and hence, initial supplies will be limited. Additionally, the logistics of distribution and administrative capacity of vaccines in a large country like ours could potentially cause delays in making the vaccine available to everyone.

So, it may take many months until everyone is immunised.

In such a case, a plan is essential to prioritise the groups who need to be vaccinated urgently and groups who can wait until supplies increase.

Who should wait

Clinical trials usually take an average of six to seven years. Even then, no vaccine is 100 per cent effective. However, the pandemic has expedited the speed at which the clinical trials are run and a potential vaccine could be made available within a year.

Considering that the vaccine is approved following the highest safety standards, its effectiveness is still uncertain. Due to weak immune responses in older adults, they would still require a higher dose of the vaccine for it to be effective. Hence, it is best to avoid vaccinating older adults in the first phase until more information is made available.

The current clinical trials are based on healthy adult volunteers (18-55 years) with no comorbidities. As limited evidence will be available from the trials for the safety and efficacy of the vaccine for individuals with co-morbidities (eg, diabetes, cardiovascular disease, chronic kidney disease, etc), rare diseases, and children, they may need protection from infection through indirect means. Also, with the data available so far, children are half as susceptible to SARS-CoV-2 as adults. Therefore, they can be protected from infection by immunising their contacts.

Economic and social wellbeing is the need of the hour. In response to the pandemic, lockdowns were imposed to curb the spread of the virus. This led to the closure of many businesses and, as a result, reduced economic activity, increase in unemployment and food and housing insecurity. Societal interactions have also been disrupted. Thus, along with public health, the focus of any vaccination strategy should take into account economic and social wellbeing.

3-phase vaccination strategy

A pragmatic approach would be to identify living and working conditions that have demonstrated an increased risk of exposure to Covid-19 infection.

In the initial phase, the vaccination should be provided to healthcare workers who are in contact with Covid-19 patients, such as healthcare workers and emergency medical services personnel.

Although they use personal protective equipment (PPE), they aren’t completely protected and are still at a high risk of infection. Prioritising frontline healthcare workers also protects the healthcare system.

Workers who are deputed for the vaccination campaign — vaccinators and supply chain workers — should be next in line as they will be exposed to thousands of people who could be Covid carriers. Similarly, other essential workers in sectors like transportation, food system, warehouse, and delivery who are at a higher risk of infection, should be prioritised. This is critical as it protects essential services and enables ramping up economic activity.

Phase 2 of the vaccination strategy could focus on protecting other essential service personnel who are needed to maintain public safety and health. Personnel involved in emergency services, public health, police, healthcare support staff, maintenance services, and workers operating electricity, water, sanitation, financial and fuel infrastructure need to be vaccinated.

To enable more economic activity to resume, other essential and non-essential workers who cannot work remotely and have higher infection risk in their workplace, such as retail and industry workers, need to be immunised.

The groups that can be immunised during phase 3 of the strategy are those involved in educational sectors, household contacts of persons with co-morbidities, farmworkers, others who cannot work remotely. The final phase can then vaccinate everyone else.

States will play a crucial role, transparency a must While all groups should be offered a vaccine concurrently, it is only possible if enough of the vaccine is available at the beginning. Since this scenario is unlikely, hard choices must be made.

Once more than one vaccine candidate is available in the public domain, more people can be immunised at the same time.

It is expected that the prioritisation and distribution plan might be formulated centrally, however, much of the implementation will be done by the state and locally.

Therefore, states should further plan to ensure vaccination is distributed and administered to the targeted groups, especially those that may be hard to reach. Finally, any allocations should be made transparent to the public alongside the reasoning to prevent any social tensions and confusions.

(Manjeera Gowravaram has a Ph.D. in RNA Biochemistry from Freie Universität Berlin and is a participant in Takshashila Institution’s GCPP (HLS) programme.)

High Cost of Covid 19 Healthcare in India

An article by Kamala Thiagarajan in BMJ.com

India’s private sector props up its healthcare, but the pandemic has exposed exorbitant and inconsistent billing. Kamala Thiagarajan reports on the patients and authorities picking up the tab

On 12 April, a businessman living in Kolkata accompanied his 57 year old mother to the government run hospital close to his home. She’d had a low grade fever for days and a history of chronic lung issues when she developed breathlessness. The hospital didn’t have a ventilator and conditions there were very bad, he says, so he instead admitted her to a privately run corporate hospital.

The hospital staff put her on oxygen and administered a covid-19 test, which turned out positive. Meanwhile, the hospital began billing incessantly. “There were a lot of hidden costs that I could not understand,” he says. “I wondered whether much of the medication or treatment was necessary, but whom could I check with? I didn’t have the power or strength to even complain.”

On 9 May he lost his mother, but he was told that he had to settle a bill of 1.5 million rupees (£15 750; €17 300; $20 400), which he disputed. After much negotiation the hospital finally lowered the charges to one third of that amount, which he recently settled.

As the pandemic has spread, so have demands for the Indian government to regulate the rising costs of healthcare in private hospitals, which provide the bulk of the country’s medical treatment. India has nearly twice as many private hospitals as public ones—an estimated 43 487 versus 25 7781—despite about 85.9% of India’s rural population and 80.9% of its urban population having no health insurance.2

Treatment at public medical facilities is free, but the quality of care varies greatly among states, and covid-19 has exposed the lack of government investment in terms of equipment, facilities, and staff. “Existing vacancies haven’t been fulfilled, even as government run hospitals struggle without adequate manpower,” says Inayat Singh Kakar, a public health researcher with the People’s Health Movement in New Delhi.3

Most ventilators are available only in private hospitals, and even then they’re concentrated in just seven states.1 All of this serves to drive desperate patients towards private healthcare—if they can afford it.

Measures and mixed results
In April, Sachin Jain, a lawyer based in New Delhi, filed a public interest litigation—a legal case filed in the public interest—with India’s Supreme Court, drawing attention to the high costs charged by private hospitals for covid-19 treatment. Although ongoing, the case has led many state governments to try out potential solutions, spurred on by pressure from the Central (federal) Government’s health ministry and building on the existing efforts of some states to assert some control.

The northeastern state of West Bengal announced that treatment should be completely free at public and private hospitals handling covid-19 cases, but it was unable to get most large corporate private hospitals on board. In New Delhi private hospitals were asked to apply subsidised rates on as much as 60% of total hospital beds, but many patients complained of being directed to unsubsidised beds first.4

City administrations in Bengaluru, Mumbai, and Hyderabad have successfully taken action against private hospitals, obtaining refunds for patients who had been overcharged for covid-19 treatments. The southern Indian state of Telangana has made itemised billing mandatory, to make it easier to identify overcharging.

And Maharashtra, one of the first states to be affected by covid-19, has doubled the number of private hospitals in its integrated state health insurance scheme to 1000 and extended it to families with an annual income of 100 000 rupees or less. The state also implemented a rate cap on the cost of covid and non-covid treatments at private hospitals—a measure that’s being tried throughout the country.

Rate caps
Prices for privatised healthcare should be easy enough to regulate for a federal government, says Murali Neelakantan, a lawyer specialising in healthcare. “It’s not difficult to fix a price for all hospitals,” he says, noting that the government has already done this for civil servants under the Central Government Health Scheme, enabling them to claim free treatment in government hospitals and discounts for specific treatments in 1200 privately run hospitals around the country.

“There’s no reason why [procedures] are cheaper for government employees than they are for the common man,” says Neelakantan. “The formula and the solution for price regulation exists, and it can be easily applied across India.”

So far, the central government hasn’t tried anything so wide ranging. But state governments are experimenting with rate capping in the pandemic. In a series of tweets in June, the spokesperson for the Ministry of Home Affairs in Delhi said that a committee had recommended caps in 350 private Delhi hospitals: 10 000 rupees a day for covid-19 patients who require beds and personal protective equipment (PPE); 15 000 rupees for those needing to be admitted to intensive care; and 18 000 rupees for those requiring ventilator support.5 More than 10 other states in India, including Punjab, Tamil Nadu, Andhra Pradesh, and Jharkhand, have brought in policies to subsidise covid-19 treatment in private hospitals.

Despite this, however, activists say that caps throughout the country are not being enforced. Many private hospitals simply choose not to comply, with no penalty, and different states follow different rules. Kakar says, “The price cap in Delhi included the cost of PPE, interventional procedures, high end medicines, and treatment of comorbidities during covid-19 treatment, but states like Maharashtra did not include this.”

The caps have also allowed some insurance companies to avoid paying for treatments. One patient from the south Indian city of Tiruchirappalli told The BMJ under anonymity that she and her elderly mother had been charged 320 000 rupees for a room and treatment for 11 days, after testing positive for covid-19 in July. Their insurance company said that only 100 000 rupees could be covered despite them paying for annual medical insurance cover of 5 million rupees. The company said that the remaining amount should not have been charged by the hospital in the first place, as per the government stipulations.

“They told me that I could fight with the hospital if I wanted to and refused to pay the balance amount,” she says. She chose not to because she didn’t want to be blacklisted by the only major private hospital chain in her town.

Where there’s a will . . .
Parang Mehta, a paediatrician running his own practice in Surat, Gujarat, says that it’s not right for the private sector to provide most of the country’s healthcare needs. “Even businesses should have a moral compass and refrain from exploiting human desperation,” he says. But private healthcare has long been a lucrative business in India, so question marks remain over the will of the sector to implement change.

“It is a kind of existential threat for corporate healthcare,” says Malini Aisola, co-convenor of the All India Drug Action Network, a coalition campaigning for affordable healthcare. “We need regulatory reforms that carry forward into the long term—beyond the emergency that the pandemic has created. We need a more systematic approach to regulating the private sector.”

Kakar adds, “[Private hospitals] are trying to subvert any kind of fallout of regulation, especially to make sure that it doesn’t extend beyond the pandemic. They don’t want the commercial healthcare business model to be affected.”

Still, activists say that, if there can be anything good about the pandemic, it’s that the exploitative billing practices of the private sector are finally coming under scrutiny.

Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

How will India's GDP contraction impact its citizens

An article by Vivek Kaul

India first declared its quarterly gross domestic product, or GDP, figures for the period April to June 1996. GDP is a measure of the economic size of a country. Between 1996 and March 2020, India’s GDP never contracted in comparison with the same period in the previous year.

But, as they say, there is always a first time.

India’s GDP for the period April to June 2020 contracted by 23.9 percent. But even this could be an underestimate. There are two reasons for this. One is that the real state of the huge informal sector in the country is captured only over a period of time, as more and more data comes in, and not immediately (which is why it is called informal in the first place).

Further, the data for the smaller, unlisted businesses also comes in over a period of time. The informal sector and small businesses have been hit the hardest by the coronavirus pandemic. Once this is accounted for, the chances of the GDP figure being revised downward are pretty high. And this would mean an even bigger contraction than 23.9 percent.

Dear reader, you might be wondering by now that all this is fine, but why should I be worried when it does not really impact me. At least, not in any direct way. Well, my job is safe. My earnings haven’t been impacted. I haven’t defaulted on any loans. I have paid my taxes on time. My life goes on as it was.

Here’s the thing. When the economy contracts by nearly a fourth, it is bound to impact all our lives, one way or another. We just may not be aware of it. Let’s take a look at this pointwise.

One thing that is clearly happening is that many companies are encouraging their employees to work from home. They have discovered that this way they can make them work longer (of course, no HR professional is going to admit to this). This has an impact on those working in the informal services sector.

With no need to drive to work, people will no longer want to employ drivers. Hence, jobs will be lost. This is already happening. Over and above this, the demand for app-based cabs will go down. This will mean a further loss of economic activity.

The small eating joints around and outside many Indian corporate parks that sell good food at attractive prices will continue to lose out on business. There is a grave danger of these joints having to simply shut down. Hence, coronavirus will end up destroying Pakodanomics as well.

With people having to work from home, there will have to be a basic redesign of a few things. They will need more ergonomically designed furniture. Now if you are in the furniture business, have you thought of this possibility? And if you have, what are you doing about it?

Further, it might even need a possible redesign of how homes have been laid out up until now. Home wear is now selling more than formal wear and so are chappals. These are business opportunities.

The moratorium on repayment of loans taken from banks and non-banking finance companies got over as of August 31. Hence, individuals and businesses will have to get back to repaying their loans, unless the bank agrees to restructure it. Let’s say you run a business and are dealing with another business (possibly as a supplier or a customer) that is in a financially stretched situation right now. The owner of the business might simply decide to shut down. If he is a supplier to your business then you need to look for a new supplier. If he is a customer then he might default on what he owes your business as well. These are possibilities that you need to look out for.

While the economy on the whole contracted by 23.9 percent, consumption as a whole contracted by 26.7 percent. If people cut down on consumption, it basically means they are spending less than before. This works in various ways. First, businesses on the whole see a fall in revenues and a fall in profits. This means that the employees are bound to be impacted.

Many businesses, in order to stay afloat, have fired employees. Some have cut salaries. Some others have rescinded on the job offers they made. Even businesses that are on a strong wicket have given only bare-minimum increments to their employees this year.

This can have a multiplier effect. Let’s say you run a kirana shop in an area where many people working in the BPO sector stay, and have lost their jobs. It is but natural that they will cut down on their spending and your earnings will fall as a result. It is worth repeating the cliché here that one man’s spending is another man’s income at the end of the day.

Further, many big businesses have publicly announced that they are putting all their expansion plans on the backburner currently. If businesses don’t expand, then a fresh set of jobs don’t get created. This impacts those who are just about ready to enter the job market. Imagine the fate that awaits all the engineers and MBAs who will pass out in the summer of 2021. How many of them will actually find jobs? Other than impacting them, it will also impact their immediate families, perhaps financially but definitely emotionally. The dreams of a bright future for their progeny will be shattered, may be briefly, may be for a longer-term.

Of course, the direct impact of the contraction is already being felt by people working in airline, hotel, tourism and cinema businesses. If they haven’t been fired yet, their jobs are definitely on the line. Banks and other corporates are cutting the rentals they pay for their branches and offices. This will impact the incomes of people who own such property. It will also impact the future prospects of those in the business of building such property.

To conclude, the impact of an economic contraction on an average individual isn’t always in a direct way, like job losses or salary cuts. There are indirect ways as well.

Dear reader, since no one knows you better than you yourself, you need to sit and figure these effects out. If you haven’t thought of any negative effects already, then clearly you haven’t heard the bad news yet.

Commercial realty's reboot during Covid

An article from "The Hindu" by Nidhi Adlaka

Road ahead The office leasing market is expected to recover from early 2021

Demand is set to soar for shared spaces and large business parks

Companies may have quickly adapted to the new working normal — virtual meetings, home offices and online events — but the commercial market has not been as swift to overcome Covid-linked uncertainties. Similar to other asset classes, a number of deals in the office segment have been put on hold or pushed to subsequent quarters. With corporates and MNCs working towards reshaping their office space requirements and work culture, the commercial real estate sector is in for a much-needed overhaul.

After March, there was widespread anticipation that office space demand will see a major decline, but current trends suggest otherwise, says Santhosh Kumar, Vice-Chairman, Anarock Property Consultants. Kumar is seeing a gradual pick-up in demand momentum in key cities. “All stakeholders, including developers, were quick to adjust to new realities and changed their business strategies. Some MNCs are now on an office leasing spree,” he says.

With leasing and construction activity coming to a standstill in the first few months of the lockdown, research by Savills India reveals that total leasing declined by almost 60% in H12020 across six major cities to 13mn sq. ft (as compared to the year-ago period). “With businesses gradually opening up over the last one month, we expect that fresh supply and leasing activities will improve in the second half of the year,” says Anup Vasanth, Managing Director.

Tracking progress
Before COVID-19, the average rental yield of commercial properties was 6-10%. However, with the demand for commercial properties sliding, there is a marginal dip in commercial rental yields, finds an Anarock report.

With many companies opting for work-from-home (WFH), office space tenants are able to bargain with their landlords, says Kumar. He, however, predicts that the demand slowdown and low rentals might last only for a short period of time.

Sanjay Dutt, Chairman, FICCI Real Estate Committee, says that India’s office market has shown nearly 98-99% rent collection. With relevant micro market vacancies being low and even some marginal rental growth, he thinks its sustainability is demonstrated. This can be attributed to the fact that office space is linked to global consumption complemented by cost arbitrage, talent pool, scale, competitiveness, and geopolitical advantage, he said in the recent Knight Frank-FICCI-NAREDCO Real Estate Sentiment Index Survey.

Despite the temporary halt in construction activities for a significant portion of Q2 2020, the first quarter witnessed an increase in additional office stock compared to the first half of 2019 — growing to 3.5mn sq. ft from 2.8mn sq. ft. “This can be attributed to some earlier plans for the phased launch of quality office spaces by developers preparing to meet the expected demand from MNCs,” says Vasanth.

Most of these buildings came into the market before the pandemic and some still await completion certificates.

Chennai’s market
Chennai closed 2019 with an absorption of 6mn sq.ft. In the January-June period last year, the city had absorbed 2.5mn sq.ft and H1 2020 is not far behind at 2mn sq.ft. A large chunk of this, however, is from prior commitments, says Juggy Marwaha, CEO, Commercial, Prestige Group.

Till date, Chennai’s absorption has been 2.8mn sq.ft and factors that have driven demand include the rush towards SEZs due to the Sunset Clause (which came into effect on April 1).

As Marwaha explains, a certain level of disruption has been caused with many mid-sized and start-up companies giving up space, largely in the CBD area, and larger clients leaving in the suburban and peripheral micro-markets across various asset grades.

Slightly above 1mn sq.ft. of office space has been exited across micro-markets and Grade A, B, and C assets. The vacancy still stands below double digits. With Chennai easing lockdown restrictions, market sentiments and demand is expected to become robust in the next few months in places such as OMR, Mount-Poonamallee and CBD.

Cost saving debate
Over the next few months, there will be pressure on companies to cut costs and the WFH element is likely to impact new leasing in the short term. However, the office leasing market is expected to recover from early 2021, according to Savills India report.

The pandemic has opened conversations around contractual obligations, lock-in periods, exit notices, and force majeure clauses among other things, from both a developer and occupier perspective.

In the short to medium term of 6-12 months, there will be good quality stock available to occupiers, and the market may thus lean towards being tenant favourable.

There is a question about how much WFH might have impacted rentals or cost-cutting for companies. Market studies show that even with 50% WFH, cost savings for large occupiers are minimal — just about 1% of their operating income, says Aditya Virwani, CEO, Embassy Group.

He quotes surveys that have demonstrated “that more than 90% employees miss the office work environment given lack of social interaction, IT issues, low motivation levels etc”. Several large occupiers are exploring strategies to bring employees back to the office, says Virwani. “We do not foresee any major reduction in the office footprint of bluechip companies.”

New trends
Another trend that’s picking up pace is co-working. “The demand for flexible office spaces is increasing and will continue to drive demand over the next quarters. This is largely because there is a possibility that start-ups and other businesses that occupied expensive spaces may want to move out,” says Kumar of Anarock.

In addition, companies need to get used to social distancing norms at the workplace. “They will have to de-densify their office spaces. From 80 sq.ft. per employee, the space allocated is being increased to 120-130 sq. ft. per person,” he says.

IT/ITES companies that prefer quality spaces from prominent developers continue to seek out large tech parks. “Tech parks offer facilities like thermal scanning of employees, periodic disinfection of buildings, visitor tracking, etc., which companies would otherwise need to take care of independently in standalone buildings,” explains Virwani.

The business park concept is gaining prominence in Chennai, he says. “The city has primarily seen a concentration of Grade B buildings at the city centre. However, with time, the Chennai market has become open to modern Grade A spaces in business parks. With increasing health concerns, companies are now more concerned about employee safety.”

Tax incentives by Indian Government to support domestic companies

Section 115 BBA

The new section – Section 115BAA has been inserted in the Income Tax Act,1961 to give the benefit of a reduced corporate tax rate for the domestic companies. Section 115BAA states that domestic companies have the option to pay tax at a rate of 22% plus sc of 10% and cess of 4%. The Effective Tax rate being 25.17% from the FY 2019-20 (AY 2020-21) onwards if such domestic companies adhere to certain conditions specified. The company need not pay tax under MAT if it opts for Section 115BAA.

The new effective tax rate, which will apply to domestic companies availing the benefit of section 115BAA is 25.168%. The break up such tax rate is as follows:

Such companies will not be required to pay Minimum Alternate Tax (MAT) (MAT) under section 115JB of the act.

The domestic companies opting for section 115BAA will not be able to claim MAT credits for taxes paid under MAT during the tax holiday period. The companies would not be able to reduce their tax liabilities under section 115BAA by claiming MAT credits. The CBDT may issue a clarification on MAT credits in case of companies opting for tax under section 115BAA.

Moreover, the domestic company opting for section 115BAA shall not be allowed to claim set-off of any brought forward depreciation (additional depreciation) for the assessment year in which the option has been exercised and future assessment years.

There is no timeline for the domestic companies to choose a lower tax rate under section 115BAA. So such companies can avail the benefit of section 115BAA after claiming the brought forward loss on account of additional depreciation and also utilising the MAT credit against the regular tax payable if any.

Section 115 BAB

A new manufacturing company can exercise the option to be taxed under section 115BAB. The company has to exercise the option on or before the due date of filing income tax returns i.e usually 30th September of the assessment year. Once the company opts for section 115BAB in a particular financial year, it cannot be withdrawn subsequently.

The new effective tax rate, which will apply to domestic companies availing the benefit of section 115BAA is 17.16%.

Russian vaccine : opinion

By Sarah Caddy - Welcome Trust Clinical Research Career Development fellow

Release without phase III trial entails numerous risks

The announcement by Russia’s president, Vladimir Putin, that the country has developed and approved the world’s first SARS-CoV-2 vaccine1 raises many questions. The global scientific community is concerned that this is a high risk move on the part of the Russian government.

The vaccine, named Sputnik V, was developed by the Gamaleya Research Institute of Epidemiology and Microbiology, based in Moscow and supported by the Russian Ministry of Health. It uses an adenovirus vector to deliver the gene for the SARS-CoV-2 spike protein, a similar approach to that being used by the vaccine development team at the University of Oxford and AstraZeneca, albeit with different adenovirus vectors. The Russian vaccine is based on two human adenovirus vectors (Ad5 and Ad26), whereas the Oxford vaccine uses a chimp vector (ChAdOx).

Concerns
The main concern is that the Russian vaccine has not yet been through a phase III clinical trial. Such a trial, typically involving over 10 000 volunteers and comparing the vaccine with placebo, would seek to prove vaccine efficacy as well as safety. Without phase III data we don’t know whether the Russian vaccine can protect people from SARS-CoV-2. Claims of efficacy are currently being based on unpublished data from two small phase II trials, descriptions of which are outlined in ClinicalTrials.gov23 A website for the vaccine launched by the Russian Direct Investment Fund states that that all 76 volunteers who received it developed high titres of SARS-CoV-2 specific antibodies and good cellular immunity.4 However, as it is still unclear what the ideal protective immune response to SARS-CoV-2 is, it is not possible to know whether these people would be protected against covid-19.

Nor is it known whether the vaccine is safe. No “serious complications or side effects” were reported in the phase II trials,1 but they included only a small number of healthy participants. More extensive testing has been performed for a similar Ad5 based covid-19 vaccine in Wuhan, where no serious adverse events were documented in 382 healthy volunteers.5 But neither vaccine has been tested in people with pre-existing health conditions, who are arguably most in need of protection. Furthermore, there is theoretical concern that vaccine induced SARS-CoV-2 antibodies may have the potential to worsen infection or cause immunopathology, so called antibody dependent enhancement of disease.6 Though this risk is now estimated to be low, without extensive testing we cannot accurately predict outcome. The health of people receiving the Russian vaccine will consequently need to be closely monitored.

Any negative effect of the Russian vaccine could extend far beyond the people physically receiving it. An ineffective, or even dangerous, vaccine has the potential to substantially diminish confidence in and uptake of other vaccines that are subsequently approved. A European survey of over 7500 participants found that 19% of people were unsure they would take a SARS-CoV-2 vaccine, and 7% said they would refuse vaccination altogether.7 A poorly performing vaccination programme in Russia could increase vaccine hesitancy internationally.

Regulatory pathways
Russia’s vaccine has been able to skip phase III clinical trials because of differences in medicine regulatory pathways across the world. Many countries and regions have their own regulatory body—for example, the European Medicines Agency or the Food and Drug Administration in the US. Additionally, the World Health Organization prequalification team provides regulatory guidance to countries without regulatory capacity.8 Many of these agencies work closely together, and a recent meeting of the International Coalition of Medicine Regulatory Authorities agreed a set of principles for conducting phase III clinical trials for SARS-CoV-2 vaccines.9 Russia’s medicine regulatory body, however, acts independently of other agencies, and its decision making processes are not always fully transparent outside of the country

According to WHO guidelines on clinical evaluation of vaccines,10 six vaccine candidates are already ahead of the Russian vaccine in the standard development pipeline. These candidates are all in phase III trials in multiple countries.11 The trials are expected to take months to complete, and the vaccine candidates are unlikely to be equally effective. Phase III trials are reported to be about to start for the Russian vaccine, but it remains to be seen whether this will affect any regulation and licensing of the vaccine. The Russian vaccine could still be a valuable tool for controlling covid-19, but global scepticism is high and only extensive further studies will tell. Whatever the urgency of the current pandemic situation, there is the possibility that the release of an untested vaccine could wreak long term damage on international efforts to contain covid-19.

Acknowledgments

I thank Gordon Dougan for constructive comments.

Footnotes

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare no other interests. The BMJ policy on financial interests is here: www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf

Automating your virtual presence in Office meetings

A novel ideal

Protectionist trade policy impact on Employment

An economic paper by Alessandro Barattieri & Matteo Cacciatore


In 2018, the U.S. administration imposed new tariffs on roughly 12% of imports, sparking debates on the effects of protectionism to unprecedented levels. A distinguishing feature of recent U.S. trade policy is the focus on the access to global supply chains (Krugman, 2018, and Baldwin, 2018). For instance, tariffs against Chinese imports have heavily targeted intermediate inputs, with nearly $50 billion of imports of steel and aluminium being affected (Bown, 2018a). Such a shift of trade protection towards intermediate inputs is not an isolated episode. Hidden behind unchanging tariff policies, governments have been using temporary trade barriers (TTBs)—antidumping, countervailing duties, and safeguards—to restrict trade in intermediate inputs since the last two decades (Bown, 2018b). In particular, while governments have maintained lower tariffs on factor inputs relative to final goods, TTBs on imported intermediates have been on average higher and growing relative to TTBs on final goods

In light of these events and considerations, it is not surprising that much of the discussions on the effects of protectionism contrast potential gains in protected industries and possible negative effects on downstream sectors—the producers that use protected goods as intermediate inputs.1 However, despite the relevance of supply-chains considerations, econometric evidence on the effects of protectionism through vertical production linkages remains scant. We address this issue by studying the employment effects of TTBs in protected and downstream industries

Our contribution to the literature is threefold. First, we provide novel evidence on the role of production networks in propagating protectionism targeted to specific industries. Second, while the trade literature typically focuses on the long-run effects of permanent tariff reductions, we provide evidence on the dynamic consequences of TTBs. Third, we exploit a novel high-frequency identification of temporary trade-policy shocks at a disaggregated industry-level

The analysis proceeds in three steps. First, we identify movements in protectionism that are plausibly unanticipated and not correlated with economic fundamentals. Our approach builds on a consolidated strategy in the monetary and fiscal policy literature, following the seminal work by Romer and Romer (2004). The idea is to purge the series of interest (TTBs protection) of movements taken in response to past, current, and expected dynamics in the outcome variable of interest (employment growth). The remaining variation allows us to identify the effects of protectionism on employment within and across industries, even in the scenario in which such variation is not strictly exogenous, i.e., when other factors not affecting employment dynamics drive the residual TTBs dynamics.

We consider two alternative and complementary approaches to identify trade-policy shocks. One focuses on within-industry time-series variation, while the other one uses the panel dimension of the data. In both cases, we exploit regulation-induced lags in the opening of an investigation to impose short-run restrictions—TTBs cannot react to economic shocks within a month. We then control for past economic conditions and measures that capture expected economic outcomes. In particular, using firm-level data, we construct for each industry a benchmark measure of expected returns used in the finance literature, the market-to-book ratio (e.g., Pontiff and Schall, 1998, and subsequent literature). With panel data, we also include industry and time fixed effects, stronger controls for unobserved heterogeneity and common shocks.

Our analysis yields three main results. First, protectionism has small and short-lived beneficial effects on industry employment. Across specifications, an increase in the share of imports subject to TTBs equal to 2 percentage points (the average import share affected by TTBs in the episodes we analyze) leads to an employment increase at most equal to 0.15 percentage points on average. The response turns negative after approximately one year. The effects are in general statistically insignificant. This finding is consistent with different explanations, including the fact that TTBs affect profits (e.g., markups) rather than output in protected industries, heterogenous responses across producers (e.g., a different exposure to products covered by TTBs), as well as the presence of offsetting forces determining industry’s output demand (e.g., expenditure switching versus negative income effects).

Second, protectionism has negative, persistent, and statistically-significant effects on employment in downstream industries. Our estimates imply that a uniform 2 percentage-point increase in the share of imports subject to TTBs in upstream industries generates an average employment decline up to 1 percentage point after two years. Third, the downstream employment loss is accompanied by a statistically significant increase in both intermediate-input and final producer prices. From a timing perspective, the peak of the price increase precedes the peak of the employment decline, suggesting that it is indeed a loss of 3 competitiveness that causes employment losses. In addition, employment falls more on average when goods are more substitutable

Prices

There exist alternative possible explanations for the negative effects of protectionism on downstream employment. For instance, when an intermediate input is subject to TTBs, downstream producers may find it hard to quickly replace it, ending up paying a higher price. Alternatively, producers may switch to potentially less-efficient suppliers, facing higher prices relative to the pre-TTBs scenario. While these two scenarios have different implications for the response of imports, marginal costs and final-producer prices in downstream industries are predicted to increase in both cases. In turn, higher prices reduce competitiveness, lowering demand and employment.

Deadly Premonition 2 : It is back

The Verge article by Sam Byford

Deadly Premonition 2: A Blessing in Disguise is almost as awkward to review as Deadly Premonition must have been to follow up. So let me just get this part out of the way: Deadly Premonition fans, by which I mean people who genuinely, unironically liked Deadly Premonition, may well dig this game. It is delirious in most of the same ways as its predecessor, from the surreal writing to the endlessly twisting plot.

Should anyone else play it? Well, no.

One reason is simple. Another is more complex. The simple reason is that anyone who didn’t play Deadly Premonition will have no idea what is going on in this game, which serves as both a sequel and prequel while making no attempt to explain itself to newcomers. But the thornier problem is that Deadly Premonition 2 is, by any reasonable standard, a deeply flawed game to an even greater degree than its predecessor, and uninitiated players are unlikely to be as forgiving a decade on.

The original Deadly Premonition found an unusual path to Western fandom. While it was a full-priced release in Japan under the name Red Seeds Profile, the US version got a new title and a $20 price point that reflected its low budget and less than impressive production values. The critical response was mixed, to say the least — IGN famously gave it a 2/10 — but word soon spread about this bizarre Twin Peaks-influenced survival horror game from Japan. It’s now considered a true cult classic.

I often hear the phrase “so bad it’s good” or comparisons to The Room thrown around in reference to Deadly Premonition, and I think that’s way off. The Room is a terrible movie made by someone who had too much money and no self-awareness, which is what ultimately makes it watchable. Deadly Premonition, however, is a great game at its core. It had terrible graphics, awful voice acting, and clumsy combat, sure, but most of its flaws were a consequence of its budget. The writer and director, Hidetaka “Swery” Suehiro, knew exactly what he was going for. There is nothing like Deadly Premonition’s unhinged blend of horror, comedy, and pop-culture references, and for many, the technical flaws only added to the B-movie charm.

Deadly Premonition 2 doesn’t get let off so easily. This is a Switch-exclusive release, and no one ever expected a sequel to happen, so it is fair to say that Nintendo’s backing for the project probably exceeds whatever collection of shoestrings was used to fund the original. Despite this, Deadly Premonition 2 is a technical disaster. It adopts a new semi-cel-shaded art style reminiscent of Swery’s Xbox One game D4, and it does look relatively sharp on the Switch’s screen. But the overall aesthetic is a visual mess, and the performance often drops well below 20 frames per second.

Judging by reactions I’ve seen to previews of Deadly Premonition 2, fans of the original may well argue that this is exactly what they’d expect or even hope for. Swery himself has publicly dismissed concerns about the frame rate. And I admit it would have been a little weird to see a Deadly Premonition sequel out of nowhere with photorealistic graphics at 4K / 60fps. But I would argue that it’s even weirder to see a console-exclusive game in 2020 that looks and runs like this. It made me nauseous at times. The total lack of an invert-look option did not help matters.

I’m reminded of my time reporting a Polygon feature on the history of the low-budget Earth Defense Force series, which is notorious for its inversely proportional relationship between frames per second and giant alien bugs on-screen. “From my perspective, if I asked the player if they want a very stable and conservative gameplay experience, or something extraordinary with some technical issues, which game would they prefer?” director Takehiro Homma asked me. “I think the latter is more appealing.”

Deadly Premonition 2 is not showing me anything extraordinary. Often, it’s just showing a dude talking to himself at a dinner table with admittedly witty dialogue, and the frame rate still somehow suffers. Things get even worse when he steps outside on his skateboard. If anything, the original Deadly Premonition had better performance.

Deadly Premonition 2’s core conceit is essentially a direct lift from the first season of True Detective, where you follow a young sleuth in the past and catch up with his ragged, world-weary form in the present for another perspective on the main story. (The past scenes are also set in Louisiana, just to drive the reference home.)

The game plays out in an open world of sorts, letting you explore a small town and gather information on a murder — although the detective elements are more about finding things on the map than using any actual brainwork. There is also combat, as with the first game, and unsurprisingly, it isn’t very good here either.

I could tell you more about how Deadly Premonition 2 plays, but really the answer is just “badly,” and that won’t — and shouldn’t — put off anyone who wants to play it anyway. I do enjoy the characters and the world and the overwhelming sense that everything has been scooped directly out of Swery’s id with a shovel. I don’t think any of that is an excuse for releasing a game that feels like it’s running on a PS2 emulator, but I know there are people who won’t mind. As some guy once said, time is a flat circle. This game repeats what came before it — for better and worse.

Deadly Premonition 2 reminds me of last year’s Shenmue III. That was a similarly unlikely sequel that played on nostalgia; the overall visuals were updated, but the simple character models and knowingly cheesy voice acting felt of a part with the decades-old predecessors. Deadly Premonition 2, in turn, certainly does what it can to re-create the experience of playing the original game.

But the difference with Shenmue is that those games were technical marvels at the time, so deliberately evoking that Dreamcast-era vibe makes a certain degree of sense today. Deadly Premonition was great despite its technical issues, not because of them. I’m not asking for a AAA-standard sequel, but it would have been nice if Deadly Premonition 2 felt fit for purpose as a Switch game.

Still, as a Deadly Premonition game, I have to say that A Blessing In Disguise hits the spot. If you liked what was actually good about the predecessor — the writing, the sense of humor, and the multilayered plot — this is a reasonable sequel. I just wish it had improved on the things that weren’t so great instead of leaning into them.

The Silent Patient by Alex Michaelides

One of my fastest reads ... a pacy intriguing thriller

Can nutrition support healthy cognitive ageing

by Amy Jennings .. Senior Postdoctoral Fellow

Around 50 million people worldwide have dementia, the main form of which is Alzheimer’s disease. Dementia is a major cause of disability and dependency in older adults and, owing to expanding and ageing populations, its prevalence is expected to almost triple by 2050. This increase is being partly offset by decreasing age standardised dementia rates in some high income countries, attributed to more years of education and improved cardiovascular health.1 In England and Wales, dementia is the first and second leading cause of death in women and men, respectively, responsible for 16.3% and 8.7% of total mortality in 2017 (www.ons.gov.uk). Almost two thirds of cases of dementia are in women. The cause of this difference between the sexes is poorly understood.2

Interventions to improve cognition and reduce dementia risk
No licensed drugs are available that prevent or reverse dementia. For Alzheimer’s disease four drugs are used to treat symptoms temporarily (donepezil, rivastigmine, galantamine, and memantine). Therefore, behaviour which prevents or delays progression of neuropathology and brain vascular dysfunction could help to reduce the individual risk and population burden of the disease. The 2014 report, “The trajectory of dementia in the UK–making a difference,” estimated that a two or five year delay in the onset of dementia would reduce the number of people with the disease in the UK by 19% and 33%. respectively, by 2050.3 In a US based analysis, Brookmeyer and colleagues predicted that interventions associated with a five year delay would almost halve cases of dementia over 50 years.4

It is estimated that about one third of cases of Alzheimer’s disease worldwide are attributable to modifiable risk factors,5 many of which are nutrition and lifestyle dependent (depression, mid-life obesity, mid-life hypertension, and type 2 diabetes). Cardiometabolic health is a major determinant of age related cognition function and risk of dementia. Research into the role of nutrition in age related cognitive decline is in its relative infancy compared with other chronic conditions, such as cardiovascular diseases, type 2 diabetes mellitus, osteoporosis, and gastrointestinal disorders.

Although the results are not fully consistent,6 a growing body of prospective cohort evidence shows that bioactive components of food are associated with a reduced risk of dementia.78 Much of the research has considered dementia as a composite, despite the recognition that owing to differences in pathology, dementia subtypes (eg, Alzheimer’s disease, vascular dementia, dementia with Lewy bodies) are probably influenced by differing dietary factors. Furthermore, a large retrospective cohort study9 has shown that behaviour, including a healthy diet, partly mitigates the penetrance of a high dementia genetic risk score. Model systems have provided insight into the potential underlying molecular and physiological mechanisms for the associations observed, including improved cardiometabolic health and brain perfusion, and direct effects within the brain on neuronal function, energy metabolism, and β amyloid processing.

The randomised controlled trial evidence is more limited and less convincing,710 with cognition and brain volume (as assessed by MRI) as the main study endpoints, and few primary prevention randomised controlled trials with incident dementia as an outcome measure.

Nutrition and cognition

Some evidence suggests that individual food bioactive components protect cognitive health (for review see Scarmeas et al8), including B vitamins, antioxidant vitamins, selenium, vitamin D, medium chain triglycerides, and long chain omega-3 fatty acids (see supplementary table on bmj.com). This evidence is not conclusive, however. Any effects of intervention with such individual components are most likely to appear after long term exposure, and in those with a low baseline habitual intake. Evidence that nutrition has a beneficial effect on brain function is stronger for healthy dietary patterns, probably because the synergistic effect of several bioactive components affects many physiological processes and signalling pathways underlying cognitive function and decline. Intuitively, one would predict that the effect of nutrition would be more evident in people who are still cognitively healthy or prodromal, rather than in those with diagnosed dementia, where significant neuronal loss has already occurred, but this has not been rigorously tested.

Here we focus on fish/the omega-3 fatty acid docosahexaenoic acids (DHAs), ketogenic interventions, and a plant based dietary pattern (eg, Mediterranean diet) as approaches to nutrition with a strong potential to mitigate age related cognitive decline. The state of advancement of knowledge and inconsistencies in these areas provide insight into the research approaches used and the challenges encountered in confirming nutrition-cognition causal relations, especially during ageing.

Omega-3 fatty acids and improved brain function

Oily fish, which includes salmon, mackerel, herring, fresh tuna, and sardines, are the almost exclusive dietary source of the long chain n-3 fatty acids, eicosapentaenoic acid and docosahexaenoic acid (DHA). Algal oil capsules provide a vegan source of DHA. The brain is highly enriched in DHA, which constitutes 15% of brain lipids compared with less than 5% in most other tissues.11 The role of DHA in the developing fetal and infant brain is widely accepted. In prospective cohort studies, high fish and DHA intake has been consistently associated with improved cognitive health in older age, with a 10-30% reduced risk of Alzheimer’s disease and death, brain atrophy, and cognitive decline, and effect sizes equivalent to two to four years of ageing1213141516; there is some indication of greater effects in women.15 In a meta-analysis of 21 cohort studies, a 100 mg increment of dietary DHA was associated with lower risks of dementia (relative risk 0.86, 95% confidence interval 0.76 to 0.96) and Alzheimer’s disease (0.63, 0.51 to 0.76).14 Fish is also a source of multiple nutrients needed by the brain, including vitamin B12, selenium, and vitamin D, which may contribute to the observed cognitive benefits. Thus, where possible, fish itself rather than fish oil supplements is recommended as a source of DHA.

For a dietary component such as DHA/fish, which could be considered a signature of an overall healthy diet (such as a Mediterranean-style diet discussed below) and healthy behaviour, the possibility of residual confounding should be considered, as some of the cognitive benefits associated with DHA seen in prospective cohorts could be due to a yet unknown factor associated with intake,17 and the benefits associated with eating fish and DHA could be biased.18

A number of randomised controlled trials have reported mixed findings with DHA supplementation over periods of up to three years (see supplementary data). DHA is one of the bioactive ingredients in Souvenaid (Fortasyn Connect) medicinal food, designed to support cognitive ageing. In the LipiDiDiet trial, Souvenaid had no effect on the primary outcome measure, but was associated with an improved clinical dementia rating score and reduced hippocampal (a main brain region affected in Alzheimer’s disease) atrophy.19

Response to DHA interventions is heterogeneous and may partly depend on DHA and cognitive status at baseline. Cognitive benefits are reported for healthy younger adults20 and in mild cognitive impairment,21 in contrast to those with more advanced disease.22 Early indications are that APOE4 carriers (25% of white populations), and particularly older women with the APOE4 variant, may have lower brain DHA uptake and status, and would benefit from higher dose DHA supplementation.22324 For DHA and other dietary components, several variables need to be considered, including delivery to the brain and time taken to reach a steady state, and whether the cognitive benefits are direct effects on brain structure, perfusion, or metabolism, or an indirect effect attributable to, for example, cardiometabolic health. Brain DHA half life is estimated to be 2.5 years,25 and thus supplementation periods of at least a year are probably needed to detect the cognitive benefits associated with DHA enrichment of neuronal cells, and effects on β-amyloid and tau protein metabolism and synaptic plasticity.226

Brain glucose use, ketones, and cognitive health

One of the challenges facing the ageing brain is a chronic deficit in brain glucose uptake. Cognitively healthy older adults have about 7-8% lower brain glucose uptake than younger adults, a decline accentuated in mild cognitive impairment (the prodromal phase of Alzheimer’s disease) and even more so in Alzheimer’s disease itself.27 Although low brain glucose could be a consequence of the disease process, two facets of the declining glucose uptake, brain cell loss, cognitive decline continuum suggest that this interpretation should be reconsidered. Firstly, brain glucose uptake is already lower in those at risk of Alzheimer’s disease (that is, older age but still cognitively normal, carriers of the presenilin mutation or APOE4, or type 2 diabetes) but before their cognition declines.28

Secondly, studies with positron emission tomography imaging and a ketone tracer (11C-acetoacetate) show that, unlike glucose, brain ketone uptake is normal during ageing, mild cognitive impairment, and Alzheimer’s disease.293031 Ketones are the brain’s second most important fuel and, as for glucose, brain ketone uptake is an active, transporter mediated process. Hence, many of the brain cells in which glucose metabolism is deteriorating owing to age or Alzheimer’s disease are not apoptotic (or dead) because they can still metabolise ketones. Rather, they are gradually becoming energy (glucose) starved, but perhaps their function could be revived or maintained by ketones, an emerging therapeutic concept called “brain energy rescue”.32

Under normal circumstances, glucose supplies about 95% of the brain’s fuel. It is, however, effectively replaced by ketones (β-hydroxybutyrate and acetoacetate) when dietary carbohydrate or total dietary energy is limited. Furthermore, when a ketogenic supplement is included in the diet, the brain of someone with mild cognitive impairment or Alzheimer’s disease uses ketones in direct proportion to the increased ketones provided by the circulation, thereby sparing brain glucose use.3334

Recent experimental clinical studies have shown that brain energy rescue with ketones is associated with improved cognitive outcomes in both mild cognitive impairment and Alzheimer’s disease. These studies used either a very low carbohydrate (ketogenic) diet353637 or 20-30 g/day of ketogenic medium chain triglyceride supplement.343839 With ketone positron emission tomography imaging, two of these studies showed that not only did ketones access the brain of someone with mild cognitive impairment37 but that improvement on several cognitive tests was directly proportional to the rise in plasma ketones,34 implying a direct mechanistic link between restoration of brain energy levels by ketones and the improved cognitive performance. Ketogenic interventions may also be disease modifying because preclinical and clinical reports show that the neuropathological process involving accumulation of the dementia associated proteins, amyloid β and phosphorylated tau, can be partially blocked by ketogenic supplements.374041 These results are encouraging but compliance is low with ketogenic diets, and ketogenic medium chain triglycerides can cause gastrointestinal discomfort. Thus more work is needed to optimise ketogenic interventions (dose, duration, formulation) and test them in larger randomised controlled trials in order to convincingly assess their efficacy in improving cognitive outcomes in people with mild cognitive impairment or Alzheimer’s disease. Ketogenic interventions may indirectly affect cognitive outcomes, in part, by improving insulin sensitivity or stimulating weight loss; they would also be predicted to be more efficient in slowing down Alzheimer’s disease if combined with exercise.42 Given the emerging evidence for the cardiometabolic safety of the ketogenic diet and the growing interest in its use to treat type 2 diabetes,43 a long term controlled intervention assessing its effect on cognitive outcomes and risk of Alzheimer’s disease is warranted.

Dietary patterns and cognitive health

Recent research has moved away from the reductionist approach to nutrition, health, and chronic disease,17 and focused on the effect of dietary patterns, such as the Mediterranean diet, DASH (Dietary Approaches to Stop Hypertension) diet, and the hybrid MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet. Additionally, the World Health Organization and Public Health England have advocated whole diet approaches to delay or prevent cognitive decline.744 A Mediterranean diet is high in fruits, vegetables, olive oil, whole grains, unsaturated fatty acids, and fish, with restrictions of red meat, and moderate but regular drinking of alcohol. A meta-analysis of 34 168 participants showed that higher adherence to a Mediterranean diet was associated with a 21% reduced risk of developing cognitive disorders and a 40% reduced risk of Alzheimer’s disease.45 In a recent analysis of the EPIC (European Prospective Investigation into Cancer and Nutrition)-Norfolk cohort, the global cognitive benefit of high versus low adherence to a Mediterranean diet was equivalent to 1.7 fewer years of cognitive ageing.46

Numerous foods in modern Western-style diets are not traditionally included in a Mediterranean diet, such as high fat dairy products, processed meats, carbonated drinks, sweets, and pastries. The PREDIMED, MIND, and DASH diets are Mediterranean-style diets and all three improved cognitive outcomes,4748 with respectively a 53%, 54%, and 39% lower incidence of Alzheimer’s disease after 4.5 years.49 A multidomain lifestyle intervention trial (FINGER), which included modified eating behaviour as one of four concurrent interventions, improved cognitive outcomes. After two years, a 25% improvement in global cognition (as assessed by the neuropsychological test battery), and higher executive function (150%) and processing speed (89%) was evident in the intervention versus control group.5051 These findings indicate that whole diet approaches that encourage Mediterranean-style elements and discourage energy dense foods typical of a Western-style diet are beneficial for cognitive health. Although the PREDIMED study reported a lower prevalence of mild cognitive impairment after a Mediterranean diet,52 longitudinal randomised controlled trials, with incident mild cognitive impairment/Alzheimer’s disease as the primary end point, are still lacking.

The totality of evidence supports the protective effect of adherence to diets rich in whole foods for dementia and cognitive function, but there are inconsistencies within and between diets.45 Contradictory findings may be due to the geographical region, with a recent systematic review reporting that 80% of cohort studies conducted in Mediterranean regions showed significant associations with cognitive health, compared with only 50% in non-Mediterranean regions.53 Possible reasons for this geographical disparity are firstly, diet adherence scores may reflect different food patterns in Mediterranean versus non-Mediterranean countries—for example, olive oil, fish, and legumes are more commonly eaten in Mediterranean regions; secondly, adherence scores do not consider foods reflective of Western-style diets in non-Mediterranean regions; or, thirdly, in Mediterranean regions the Mediterranean diet score is “capturing” a lifestyle with characteristics protective of cognitive decline, including increased social interactions when eating, and physical activity.5455

Heterogeneity in dietary response could also be due to individual differences in nutrient metabolism. Beneficial changes in the gut microbiome, together with taxonomic shifts in microbiota composition, have been seen in those following plant based diets.56 A higher intake of plant based foods is associated with lower trimethylamine oxide levels and increased faecal short chain fatty acids, fibre degrading microbiota, and gut microbial diversity.5758 These gut microbial changes are linked to the gut-brain axis. Thus short chain fatty acids—in particular, butyrate, enhance brain derived neurotrophic factor expression, and trimethylamine oxide is linked to reduced expression of synaptic plasticity related proteins, including N-methyl-D-aspartate-receptors, both important factors for learning and memory.5960 If the microbiome can affect the gut-brain axis then diet induced changes in the gut microbiota, through plant based or Mediterranean diets associated with higher consumption of fibre, polyphenols, and probiotics could affect development of cognitive impairment. Equally, microbiome speciation and metabolism could influence the cognitive response to dietary change and may emerge as a tractable target for interventions.

In addition to the nutrients needed for brain function, the reduced content of refined sugars in Mediterranean-type diets may also help to improve glucose tolerance. This would help the ageing brain meet its energy needs (both glucose and ketones) by reducing creeping insulin resistance during ageing, thereby improving the chance of maintaining optimal cognition.

Conclusions

Prospective cohort evidence suggests that a change in eating behaviour may delay the onset of dementia, possibly by several years. The trial evidence to date is reliant on cognitive or other surrogate markers of dementia risk with often, uncertain prognostic value, and lacking sensitivity and specificity to dementia subtypes. Longitudinal randomised controlled trials with robust cognitive outcomes are still needed, ideally, with incident disease (either dementia or mild cognitive impairment) as the primary outcome. Metabolic and preclinical studies will help to provide insights into mechanisms so as to collectively provide the evidence needed to make causal inferences, fully establish efficacy, and inform policy.17 Randomised controlled trials are often expensive and long term. They should be supported by validated imaging and biochemical biomarkers of disease, both to select at risk and responsive subgroups, and to screen potentially effective interventions.

Are we yet in a position to provide dietary guidelines specifically to promote cognitive health and reduce the risk of dementia in later life? Global and national dietary macronutrient (particularly fat and carbohydrate) and food guidelines (eg, eating fruit and vegetables and reducing salt) are, in large part, based on the management of cardiometabolic risk (obesity, cardiovascular diseases, and type 2 diabetes mellitus). Given the established importance of cardiometabolic health on cognitive function (especially in mid-life), greater adherence to existing dietary recommendations is likely to reduce the incidence of dementia. To develop dietary guidelines specifically focused on prevention of dementia or improving mild cognitive decline, further research is needed to gain insight into which dietary strategies most effectively improve neuronal function and reduce neuropathology.

Controversies and research gaps

Strong associations between dietary patterns and food bioactive components in prospective cohort studies and experimental preclinical studies are often not replicated in human randomised controlled trials Randomised controlled trial design should assess whether the intervention indirectly affects systemic processes, such as cardiometabolic function or inflammation, or whether it directly affects neuronal function, brain energy metabolism, or the “hallmarks” of dementia, such as amyloid β and tau protein metabolism. The time and dose needed to produce meaningful increases in brain function must be considered in the trial design to preclude the risk of a type 2 error (false positive findings) Longitudinal follow-up randomised controlled trials are needed, ideally with incident disease as the primary outcome measure It is unclear when to intervene in the cognitive course from health to diagnosed dementia, and which interventions are best suited to dementia subtype and disease progression Little is known about the overall effect of neuropathology on the brain uptake and metabolism of dietary components Identification is needed of targeted approaches to nutrition for at risk subgroups, such as women with the APOE4 gene or insulin resistant individuals

Key messages

Global prevalence of dementia is predicted to almost triple by 2050 and no current treatments are effective Improved eating behaviour could reduce the risk and population prevalence of dementia Owing to dementia’s multifactorial aetiology, multiple dietary components that target several physiological pathways and risk factors simultaneously are needed

Changes to dietary patterns and foods (rather than single dietary components) therefore hold most promise to meaningfully improve cognition Randomised controlled trials with robust validated cognitive outcomes are needed to support the prospective cohort evidence, establish efficacy and effect size, and inform public health policy

Tell all the truth - Emily Dickinson

Tell all the truth but tell it slant —

Success in Circuit lies

Too bright for our infirm Delight

The Truth's superb surprise

As Lightning to the Children eased

With explanation kind

The Truth must dazzle gradually

Or every man be blind —

The much needed fiscal policy during covid 19 lockdown in india

There are multiple measures implemented by the government to stimulate the economy in the covid 19 induced pause in the economic activity. The question is whether they are effective and is there a magic pill which could resolve all the issues

All stimulus should have the desired effect on increased spending and resultant surge in economic activity. Unlike a developed economy, India cannot afford to provide unemployment packages like PPP (paycheck protection programme) as their tax collections are abysmally low. Indias tax to GDP ratio is c.10% as compared to US-24% UK- 34%. Also a significant majority of the labor force is outside of the payroll system in India which is evidenced by the low personnel registered for employee security schemes like EPF,NPS etc. It means that it is virtually impossible for India to have a payroll based stimulus as it would basically ignore most of the labor force.The fact that India dont have an universal health care system compounds the impact in case of surge of covid 19 cases. Thereby it is prudent for the government to have a strict lock-down to prevent a pandemic and the medical resources of State and Central Governments being overwhelmed. It provides the government a breather and focus their initiative in mitigating the constraints imposed on the economy by such strict lockdown measures.

FISCAL MULTIPLIER

Any macroeconomic study is incomplete without analysis of the desired fiscal multiplier effect of a stimulus package. It is defined by the marginal propensity to consume ("MPC") of the beneficiaries of the scheme. If the government has limited resources as is the case for India with lower tolerance for increased fiscal deficit, they should look for a package which could act like a adrenaline shot to the comatose economy.

The poor families usually tend to have the highest MPC as they usually spend most of their revenues on sustenance. It is the same essential goods and services which are allowed to operate in the lockdown. Thereby it would be an accurate assessment that any stimulus directed toward the families of the Public distribution system (PDS) i.e ration card holders below a certain level of income should have the desired impact of increased economic activity. Grocery stores also employ labor with a higher MPC thereby leading to the compounding effect of the stimulus i.e the fiscal multiplier.

CONSTRAINTS

Will the families be allowed to spend primarily on the essential goods - what if they have a outstanding loan and rental payments

The Government did announce a moratorium on rental collections but it needs to be strictly implemented and extended till the lock-down restrictions are eased. A prolonged moratorium is required on both rental and loan repayments (inc. interest) as it defeats the purpose of any benefit package if most of it used to pay a landlord or loan shark who doesnt have the desired MPC/fiscal multiplier effect.

If only essential goods and services are available then people with higher income usually tend to save as there are basically limited avenues to spend other than food during the lockdown

Thereby any benefits directly provided to individuals or families should be directed towards increased propensity to buy groceries and eliminate any redirection to leverage or rental costs.

FIRMS

The above direct stimulus to individuals through PDS or bank accounts can help to sustain the poorer section of society who are the hardest hit for a few months but what about firms. The actual engine of production for the economy, what is the impact of strict lockdown measures on them

There are three key factors which needs to be considered

a) Low margin industry - High fixed cost

b) High inventory

c) Largest employment - direct and indirect

First we need to accept that the government cannot allow a large number of firms to go bankrupt due to the govt lockdown as it would create a comatose climate which would be far more difficult to recover than the covid 19 pandemic. Thereby the Government should drive the initiative to hit the above three factors.

Any industry with high fixed cost ratio would be crippled and are most likely to go bankrupt. Even-though they can prevent working capital issues by reducing inventory or even laying off temporary staff but they cannot avoid the fixed costs like borrowing, property,plant and equipment maintenance and depreciation.

Firms carrying large unsold inventory either in the form of raw materials or finished goods would find it difficult to restart operations as the carrying cost of inventory would significantly impair their cash flows.

Large employers primarily in the manufacturing sector would require the most support as they would be the most likely to lay off permanent staff and reduce their purchase orders which would in turn precipitate a vicious cycle of supplier side unemployment who are primarily in the medium and small sector

FISCAL MEASURES

The government needs to announce a funding mechanism where the RBI directly invests in firms based on the above factors. A designated bank needs to be created under the supervision of RBI which is government funded. This "Covid 19 Bank" should extend long dated instruments carrying a reasonable coupon rate with contingent convertible and a mandatory redemption feature after 5 years. This would be the much need capital infusion required for the indian industry.

The current blanket announcement of 20 lakh crore loans targetting small and medium sector through an already struggling banking sector would only add to the ever increasing NPA issues. It is difficult for a listed banking institution to carry such higher risk on their balance sheet even if it is guaranteed by the RBI/Govt due to the higher capital costs associated with the same and its resultant impact on capital ratios.

Thereby this stimulus needs to be extended by the government directly through its segregated "covid 19 bank" rather than putting the onus on the banking sector. also there is no point in targetting small and medium enterprises as evidenced in the manufacturing sector they are usually engaged in the supplier or distribution side of large enterprises. If the orders from large enterprises dry up then there is no point of any stimulus. It is imperative that we target firms based on the above three key factors and target them for covid 19 financing instruments.

Usually financing for Large industries would help them to maintain their purchase orders and also meet the sale orders when demand picks up post easing of lockdown which brings us to the next important point ...... timing.

TIMING

The above fiscal measures shouldnt be implemented at the same time. Cause there is an inherent synergy between lockdown, stimulus and increased demand. In the initial phase of intense lockdown where only essential goods and services are allowed to operate, the focus should be on the fiscal multiplier stimulus like direct money transfer to high MPC families through the PDS and banking infrastructures with strict implementation of rent and loan moratorium which needs to be extended till the end of lockdown.

During the next phase of the lockdown when the restrictions are eased for industries to operate with minimal or reduced capacity, the first tranche of funding through the Covid 19 bank needs to be extended to firms based on the above three key factors. It is important that the funding is extended in a staggered manner which is coinciding with the gradual easing of the lockdown. There is no point in a giving a bulk amount to an enterprise with no vision on when they will have the opportunity to restart their operations.

This staggered cash flow funding which is in effect a capital instrument would provide the much needed breathing space for the industry to meet the increased demand on the projected consumption post lockdown.

In case there is extended lock-down due to non flattening of the covid 19 spread then the above industry fiscal stimulus needs to be on hold.

To reiterate i believe the following key features are required to restart the Indian economy

a) Immediate and regular stimulus to PDS families during lockdown.

b) Strict implementation of Rent and Loan payment holidays during lockdown

c) A Separate Covid 19 bank created with govt funding under the supervision of RBI

d) Staggered funding timed with the easing of lockdown of long dated instruments with contingent convertible and mandatory redemption feature after 5 years

e) Targeted funding to firms based on the three key factors

The Power of Retained Earnings

In 1924, Edgar Lawrence Smith, an obscure economist and financial advisor, wrote Common Stocks as Long Term Investments, a slim book that changed the investment world. Indeed, writing the book changed Smith himself, forcing him to reassess his own investment beliefs.

Going in, he planned to argue that stocks would perform better than bonds during inflationary periods and that bonds would deliver superior returns during deflationary times. That seemed sensible enough. But Smith was in for a shock.

His book began, therefore, with a confession: “These studies are the record of a failure – the failure of facts to sustain a preconceived theory.” Luckily for investors, that failure led Smith to think more deeply about how stocks should be evaluated.

For the crux of Smith’s insight, I will quote an early reviewer of his book, none other than John Maynard

Keynes: “I have kept until last what is perhaps Mr. Smith’s most important, and is certainly his most novel, point. Well-managed industrial companies do not, as a rule, distribute to the shareholders the whole of their earned profits.

In good years, if not in all years, they retain a part of their profits and put them back into the business. Thus there is an element of compound interest (Keynes’ italics) operating in favour of a sound industrial investment. Over a period of years, the real value of the property of a sound industrial is increasing at compound interest, quite apart from the dividends paid out to the shareholders.”

And with that sprinkling of holy water, Smith was no longer obscure.

It’s difficult to understand why retained earnings were unappreciated by investors before Smith’s book was published. After all, it was no secret that mind-boggling wealth had earlier been amassed by such titans as Carnegie, Rockefeller and Ford, all of whom had retained a huge portion of their business earnings to fund growth and produce ever-greater profits. Throughout America, also, there had long been small-time capitalists who became rich following the same playbook.

Nevertheless, when business ownership was sliced into small pieces – “stocks” – buyers in the pre-Smith years usually thought of their shares as a short-term gamble on market movements. Even at their best, stocks were considered speculations. Gentlemen preferred bonds.

Though investors were slow to wise up, the math of retaining and reinvesting earnings is now well understood. Today, school children learn what Keynes termed “novel”: combining savings with compound interest works wonders.

**********

An extract from Warren Buffet's letter to shareholders of Berkshire Hathaway in annual report 2019.

Lack of testing lead to patients being discharged with Covid 19 infections

Many patients in hospitals with covid-19 may have been discharged to care homes in March and April because of a lack of testing capacity at the time in England, auditors have reported.

The National Audit Office said that actions taken by the NHS to increase capacity meant there were enough beds and respiratory support nationally at the peak of the outbreak in April.1 Actions included postponing elective procedures, contracting with private hospitals to secure extra beds, and advising hospitals on 17 March to urgently discharge all inpatients who were medically fit to leave.

But the watchdog said that the government’s testing strategy led to some patients being discharged to care homes without being tested for covid-19 between mid-March and mid-April.

The NAO reported: “Due to government policy at the time, not all patients were tested for covid-19 before discharge, with priority given to patients with symptoms. On 15 April, the policy was changed to test all those being discharged into care homes. It is not known how many patients discharged to care homes had covid-19 at the point they left hospital.” Before the new policy of testing everyone before their admission to care homes was rolled out, around 25 000 people were discharged from NHS hospitals to care between 17 March and 15 April, the NAO said.

The auditors highlighted government guidance from 2 April that stated that care homes needed to make their full capacity available and that they could admit patients with covid-19. But it said there was a lack of data on “the extent to which care homes successfully isolated staff with confirmed or suspected covid-19.”

The NAO noted that testing of care workers with symptoms was not rolled out on 15 April. And it wasn’t until 28 April that all care home staff were eligible for tests, and the health department capped the daily number of care home tests at 30 000, to be shared among staff and residents. Testing of NHS staff with symptoms was also delayed but started on 27 March.

Until mid-April the government’s policy was to test no more than five residents with symptoms in any one care home. On 11 May the health department announced that, of around 400 000 care home residents, more than 45 000 had been tested by health protection teams. But it is not known how many residents have had covid-19, the NAO concluded.

Around 5900 care homes in England (38%) reported an outbreak of covid-19 between 9 March and 17 May, the NAO said. This peaked at just over 1000 homes in the first week of April, with some regions such as the North East more affected than others.

The NAO said it had also heard concerns from a range of health and social care organisations about the supply of personal protective equipment (PPE), with central sources up to mid-May meeting only around half of the modelled requirement.

Gareth Davies, the head of the NAO, said, “While we have not sought to evaluate government’s response in this report, our work raises some important considerations.

“Government’s ability to increase beds, ventilators, PPE, and testing has varied in part because of the number of other bodies, both national and international, with which it has had to engage. All of these issues need to be taken into account as the government plans for the later phases of the pandemic and future emergencies.”

Has Sweden’s controversial covid-19 strategy been successful?

Sweden has stood out in the global pandemic by eschewing lockdown and seemingly aiming for herd immunity. Heba Habib reports that Sweden’s public was supportive of the strategy, but is now paying a heavy price.

For months Swedish public health authorities have defended their controversial decision not to lock down the country in response to the global covid-19 pandemic. Schools were closed to children under 16 and gatherings of more than 50 people were discouraged, but bars, restaurants, and other public spaces remained open, and citizens were trusted to distance themselves.

At the heart of the government’s strategy was the implicit and controversial idea that, rather than contain the spread of disease, a country could achieve herd immunity by allowing a proportion of the population to be infected—at the expense of deaths among the vulnerable. “They did not want to put it bluntly, but seeking herd immunity was always inherent in the Swedish strategy,” says Anders Bjorkman, a professor of infectious diseases at the Karolinska Institute in Stockholm.

Herd immunity occurs when a large section of the population (generally considered to be between 50% and 90% depending on how contagious the infection is1) becomes immune to a disease or virus, therefore stopping its spread. This occurs when people have enough antibodies to repel the virus—either through having been exposed to the virus and survived, or through vaccination. Advocates claimed that the Swedish approach would be more sustainable in the long run than other countries’ harsher measures. And at first it seemed to be working.

Speaking at a press conference on 26 April, Anders Tegnell, the epidemiologist credited with the Swedish strategy, said that the rise in infections was beginning to flatten and had reached a plateau in Stockholm—the centre of the Swedish outbreak—as well as in other parts of the country.

As case numbers proliferated around the world and death tolls rose in neighbouring European countries, Swedish experts, and indeed the public, still seemed largely supportive of the strategy. According to a poll conducted between 17-19 April by independent agency Novus, 73% of 1000 respondents said they trusted the strategy of the Public Health Agency of Sweden.

But time has told a different story.

Explosive numbers
Sweden has the largest number of cases and fatalities in Scandinavia—around 37 000 confirmed cases at the time of writing, compared with its neighbours Denmark, Norway, and Finland which have 12 000, 8000, and 7000 cases, respectively. All three neighbouring countries adopted a lockdown approach early in the pandemic, which they are now slowly lifting. All three have since re-opened their borders, but not to Sweden.

Sweden recorded the most coronavirus deaths per capita in Europe in a seven day average between 25 May and 2 June. The country’s mortality rate was 5.29 deaths per million inhabitants a day (the UK ranked second with 4.48) according to Our World In Data,2 an online research publication based at the University of Oxford.

And what of herd immunity? An ongoing nationwide study conducted by the Public Health Agency of Sweden on 20 May found that just 7.3% of Stockholm residents had developed covid-19 antibodies by late April—and that was the largest number of positive results found in the country.

“It means that just like other European cities in hard hit countries, it will take a long time before the majority of the population has gone through the infection and are likely immune,” said Tove Fall, professor in epidemiology at Uppsala University.

On 11 May, the World Health Organization said that global studies had found antibodies in only 1-10% of the global population, with similar findings emerging from Spain and France. The agency warned against any country depending on herd immunity as a strategy.

Backlash

“I think we’re starting to see that the Swedish model maybe wasn’t the smartest,” said former state epidemiologist Annika Linde in a 19 May interview with newspaper Dagens Nyheter.3

More than half the deaths in Sweden have occurred in care homes for older people, something Tegnell has admitted is a “failure,” especially since a cornerstone of the strategy was protecting those over 70.

Anders Vahlne, a professor of virology at Karolinska, thinks that government advice misinformed the public by implying that those who don’t have symptoms are not contagious (the Public Health Agency of Sweden’s website states “as long as siblings or other members of the family do not show symptoms of disease they can go to school, preschool, or their workplace.”). “I think this amongst other things has caused a lot of older people in care homes to get sick and die and it’s quite unnecessary,” Vahlne told The BMJ.

IVO, the Health and Social Care Inspectorate, reported4 that 75% of the complaints it had received from the public and from care workers were about the lack of protective equipment such as facemasks in care homes. One care home worker, speaking anonymously, told The BMJ that “staff often work for 14 hours with substandard protection and continue working despite exhibiting symptoms.” The guidelines keep changing in accordance with the availability of material, they added.

“One should have known what poor preparedness we had in both healthcare and care of older people,” said Linde. “A lockdown could have given us a chance to prepare, think things through, and minimise the spread of infection.”

More worryingly, Swedish doctors have expressed alarm over the matter-of-factness with which authorities seem to be treating the plight of older and vulnerable people.

Yngve Gustafsson, professor of geriatric medicine at Umea University, noted that the proportion of older people in respiratory care nationally was lower than at the same time a year ago, despite people over 70 being the worst affected by covid-19. He expressed concern about the increasing practice of doctors recommending by telephone a “palliative cocktail” for sick older people in care homes.

“Older people are routinely being given morphine and midazolam, which are respiratory-inhibiting,” he told the Svenska Dagbladet newspaper,5 “It’s active euthanasia, to say the least.”

Last chance
Jon Tallinger, a specialist in general medicine and operations manager at a hospital in Tranås, believes that Sweden’s high death toll, particularly among older people, has less to do with the covid-19 strategy and is more a consequence of decades of privatising the healthcare system.

“The power has been taken away from the doctors and healthcare specialists and given to politicians,” Tallinger told The BMJ, “So now municipalities lack the resources to save the lives of older people and those at risk.” He added that thousands of lives could be saved if people in care homes with the virus received oxygen supplies. “Older people die because they do not receive the treatment they need.”

The government insists that Sweden’s high per capita death toll can’t be attributed to the lack of a lockdown. In a press conference on 29 May, Tegnell said the comparisons were unfair as “other countries are not reporting the actual death rates. Sweden is the best in the world in reporting the actual number of dead.” The government has given no indication that it will change its strategy beyond a ramping up of testing.

Yet even on that, Tove Fall said, “What is not so much discussed so far, is why Sweden is among the worst countries in Europe when it comes to testing.” According to Our World in Data, Sweden had carried out 23.64 tests per 1000 people as of 24 May, compared with 31.59 in the UK, 31.88 in Finland, and 44.75 in Norway.

Until April, only high priority groups—patients in hospital, high risk groups such as people over 70 or with underlying conditions, healthcare staff, and key workers—were being tested, and even then only those with severe symptoms. Minister of health Lina Hallgren pledged to increase to 100 000 tests per week by mid-May, but the government has fallen far short of that goal—recent numbers ranged from 28 000 to 33 000—sparking criticism from opposition party members and even the prime minister Stefan Lofven.6

Anders Tegnell said in a 3 June press conference that there had initially been problems with laboratory capacity “but also healthcare capacity because testing is a very complicated chain of events. You need to have staff and resources in each part of the chain.” He said that while the laboratory issue had now been fixed, the resources and training are still lacking.

Fall said the restricted and low levels of testing could have consequences for tracing and isolation efforts, and that this problem isn’t being prioritised by the authorities. “Testing of symptomatic cases in the population has not been done if the patient is not in need of hospital care or is not a healthcare worker,” said Fall. “Right now, recommendations for isolation of cases are based on symptoms only, and no household quarantine is recommended.”

Meanwhile, contact tracing has been largely abandoned since the beginning of March. This despite the fact that, according to Carina King, an epidemiologist at the Karolinska Institute, Sweden is very well positioned for contact tracing thanks to its commonplace digital identity system used to access public services and more.

Remorse?

On 2 June, Anders Tegnell was interviewed by Sverige Radio, and admitted there was “quite obviously a potential for improvement in what we have done.”6
Yet in a separate interview with the Dagens Nyheter, he said he still believed the basic strategy had “worked well.” “I do not see what we would have done completely differently,” he said, “Based on the knowledge we had then, we feel we made the appropriate decisions.”
“Other countries started with a lot of measures all at once,” he told Sverige Radio, “The problem with that is that you don’t really know which of the measures you have taken is most effective.”

“If we were to encounter the same disease again, knowing exactly what we know about it today, I think we would settle on doing something in between what Sweden did and what the rest of the world has done.”

Footnotes Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed