Salus populi suprema lex esto

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Salus populi suprema lex esto.

That, we are told, is what Boris Johnson was telling his cabinet last week while recovering from his alarmingly close brush with death from Covid-19.

Salus populi: “The health of the people should be the supreme law”. It’s from Cicero’s On The Laws, as I am sure you all knew. The prime minister, back at work in Downing Street this week, is clearly restored to his old self, quoting the classics in fine style. In this case the famous statesman whose words he was drawing on was a Roman.

I guessed he would come out with something apt but it crossed my mind he might go for his great ancient Greek hero Pericles, leader of democratic Athens at the height of its glory, who, like Boris, had to grapple with inspiring the people in a time of plague. Not only that. Pericles found himself obliged to face down the anger of the demos, who held him responsible for their misfortunes. He told them bluntly:

…the apparent error of my policy lies in the infirmity of your resolution, since the suffering that it entails is being felt by every one among you, while its advantage is still remote and obscure to all, and a great and sudden reverse having befallen you, your mind is too much depressed to persevere in your resolves. For before what is sudden, unexpected, and least within calculation, the spirit quails; and putting all else aside, the plague has certainly been an emergency of this kind. Born, however, as you are, citizens of a great state, and brought up, as you have been, with habits equal to your birth, you should be ready to face the greatest disasters and still to keep unimpaired the lustre of your name… Cease then to grieve for your private afflictions, and address yourselves instead to the safety of the commonwealth.

At that time, securing the public safety of which Pericles spoke meant fighting a war he had led them into. Unlike any leader in a modern democracy, he had the balls – if we are to believe the historian Thucydides, who was himself a survivor of that same plague – to tell the people they were wrong: for honour’s sake they had to stay the course.

Is that, one wonders, what Boris was telling his cabinet? Was he, in a subtler way than Pericles, telling his government they must brace themselves to defy early signs of rebellion against the lockdown? Did he mean that all those people left out of work or furloughed at massive state expense, and all those businesses, large and small, that stood to be ruined by months more stuck in the doldrums would just have to suck it up?

That would be a massive call to make; but as is increasingly being acknowledged, big decisions cannot be put off much longer. Do we really have to put up with this lockdown indefinitely until a vaccine has not just been discovered and tested but also made widely available, which could take a couple of years? Or can a viable early exit strategy be found that does not sacrifice lives dishonourably? Those are the questions.

Yesterday morning, as I write, Boris gave us some clues as to his expectations with a statement from a lectern outside No.10. He made clear there will be no immediate end to the lockdown; but, in a touch reminiscent of his other great hero Winston Churchill, he marked this point in terms that echoed the wartime leader’s “end of the beginning” speech. Calling on us to be patient for the moment, he looked forward to a coming time when we could “fire up the engines of this vast UK economy” again, one by one.

As may be gathered from this emphasis of mine on speeches and rhetoric, Heretic TOC will not be grappling much with science and statistics today. In the last month, after all, it has become increasingly clear that although the experts have made a vital contribution – they have succeeded in “flattening the curve” in many countries, stopping the exponential rise in deaths that could reasonably have been expected without their advice, at least in densely occupied urban areas – they are also divided as to what to do next, and the coming phase will be about political leadership and decisions.

“We’ve managed to get to the life raft,” as epidemiologist Marc Lipsitch put it, “But I’m really unclear how we will get to the shore.”

When we do finally spot the right landing place we might well find it is in Sweden – a thought I’ll allow to drift at sea a little longer.

Any number of virologists, epidemiologists and clinicians are busy deploying their navigational skills as best they can but heretics like us, along with the politicians and the public, need to ponder the implications of the ideas they put forward: Will there be long-term consequences of keeping entire countries under sustained house arrest in this emergency? Do we face a dystopian future of permanent “contact tracing”, total surveillance and zero freedom? What does the lockdown mean already for kids stuck in a totalitarian nuclear family dwelling whose walls they can never breach? On the other hand, would lifting the lockdown too early imply a callous, Ayn Rand-style abandonment of the weak and vulnerable in hospitals and care homes? Would it fail those in the health services who are already putting their lives on the line to do their duty, by risking a second peak of the disease that could be higher than the first?

Not that these deeper concerns were lost sight of last time amidst the technical issues. Heretic TOC can actually claim to have been well ahead of the (now flattening) curve a month ago. I faced some criticism by commentators for speaking in terms of “brutal utilitarian calculations” as to the value of a life, and for doubting whether our civil liberties should be trashed just in order to prolong by a few months the lives of the old and infirm.

Yes, I was a bit blunt. It would be nice to think Pericles would have “Liked” my no bullshit approach. In the absence of a thumbs up from the great Greek, though, we might note that cost-benefit calculations and trade-offs along the lines I suggested are now being increasingly seen as necessary by big cheeses of our own times. Former civil service chief Gus O’Donnell, for instance, cited NICE as a model for rational medical decision making in a Covid context, just as Heretic TOC did, focusing on a tweaked version of the “life-years” concept I introduced.

The incredible bulk of charging Boris famously flattened a 10-year-old boy in Tokyo. Now that same beefiness – or rather fatness – is being held responsible for flattening him when he had Covid-19. The PM was so badly affected by coronavirus because he is “significantly” overweight, an NHS doctor revealed in the Daily Mail yesterday. Consultant cardiologist Dr Aseem Malhotra said there is a ten-fold risk of death from the disease if patients are obese. The Mail report said Johnson, 55, has long struggled with his weight and in 2018 revealed he weighed almost 16 and a half stone, which at 5ft 9in puts him in the high risk category.

O’Donnell, as it happens, also suggested a couple of days ago that a reasonable and fair way to get out of the lockdown would be to follow the pattern set by much-criticised Sweden. It is an idea I had liked the sound of for many weeks, ever since I first heard Sweden had decided against a compulsory lockdown. That country bravely followed its own course when – as libertarian pundits put it – so many other countries were being panicked into giving up their civil liberties. The Swedes decided instead on a voluntary approach to social distancing, even keeping bars and restaurants open.

Most European countries have opted for tight compulsory lockdowns – in France you even need a printed form every time you leave the house unless you want trouble with the police. Sweden, has been castigated for letting the disease let rip as a result of its laidback style, and it is true that mortality has been high compared to neighbouring countries. But the latest figures, as I write, show that the death rate per million of population is actually somewhat lower in Sweden (233) than in the UK (319). As for Belgium (633), wow! Such comparisons are admittedly somewhat specious as the figures are collected in different ways in different countries, but all in all it is far from obvious that Sweden’s policy can be written off as foolish and irresponsible.

In any case, even if we look no further than saving lives, the death rate from Covid-19 is not the only mortality factor to consider. For one thing, there is now evidence that focusing in a blinkered way on coronavirus is already leading to cancer patients and heart attack victims not being treated in a timely fashion, with an inevitable impact on their survival chances. And, as noted last time, what should also be taken into account is the years of life likely to be lost by shutting economies down. Last time, I cited a study showing that anything more than a 6.4% shrinkage in the size of the economy would in effect mean a lockdown doing more harm than good because it would add to the final net death rate. I was rightly taken to task by commentator Andrew Meier for failing to flesh out a more detailed picture. He added: “I don’t feel we can reasonably reduce the consequences of not taking adequate measures to control the spread of the virus to just a high mortality rate.”

His point was aimed at the need to consider the wider consequences of possibly letting the disease get out of control, beyond just the death rate, and he was right – the psychological consequences of panic setting in, for instance, could be terrible, as he said. And a point more widely emphasised, quite rightly, is the very strong imperative to make sure health services are not overwhelmed, as they were in Italy, with terrible consequences not just for the lives of doctors and nurses but also the morale and mental health of the survivors and of the whole country.

If we do look beyond the Grim Reaper’s likely harvest, though, we find in Sweden what seems to me an interesting contrast with the British situation. In the UK the health system was initially in danger of being swamped. In my now considered view, the government was probably right to go (reluctantly and belatedly, like the Netherlands) down the road of compulsion but should now change course quickly to a more libertarian stance.

Sweden never faced such extreme peril. Their health service going into the crisis was in better shape than the UK’s, which was already chronically “running hot”, with bed shortages every winter and many other shortcomings after a decade of austerity. Sweden also enjoyed the great advantages of a widely dispersed population with the highest proportion of people in any European country living alone; they topped the charts, too, in those already working from home. If voluntary “social distancing” was going to work anywhere, while keeping the economy open as much as possible, this was a very good country for the experiment. The capital, Stockholm, was an exception, with a high immigrant population in multi-occupation, multi-generation households, and this is precisely where the death rate has been highest.

Failure to protect the most vulnerable, in care homes and elsewhere, has been admitted as a shortcoming by the Swedish government; but they emphasise that their strategy is to see the problem as a marathon, not a sprint: their voluntary approach, with the greater freedoms it affords, is more sustainable in the long run than severe controls against which people are likely to rebel – indeed are already doing so, especially in some parts of the US.

What is prioritised comes down, in the last analysis, not just to the relative death rates resulting from different strategies, or even to a wide range of specific pros and cons. Rather, the approach we want to take will depend on our very broadest values, our view of the sort of society we want to live in. For the moment, the Swedish people are standing by the choice their country has made.

In Britain, though, we hear that government ministers have held a series of high-level meetings with trades unions and business leaders “amid fears that millions of people will be too fearful to return to work”.  As amply documented by sociologist Frank Furedi and others, there are signs that we are becoming a very risk-averse culture. Even if the lockdown is lifted many will be afraid even to leave their houses – a poll found this was the case with around a fifth of all children.

Freddie Sayers, writing for UnHerd on the Swedish experiment, has wise words on this phenomenon:

The world becomes a place of indefinite anxiety, with the constant threat of curtailment hovering over all that is best and most human in life – family get-togethers, religious worship, children playing, plans for the future, creative projects – it risks becoming a conscribed, smaller, more fearful world. At its most extreme, a long-term “suppression state” really could start to feel like oppressive regimes of history, from the Puritans to the Communists, that misguidedly tried to remake the whole natural order in pursuit of a single definition of virtue. People who recoil from any move in this direction can hardly be dismissed, or called immoral.

Surely, in Britain, it is time to challenge the culture of cowardice that we have allowed to creep up on us in recent times. It is shameful that we are making even children scared of a disease that barely touches them. When Boris finally fires up those mighty engines he spoke of, we should at least be ready for the journey.

Salus populi suprema lex esto? Yes, but in its widest interpretation: the health of the people includes strength of the spirit as well as of the body. It depends on valuing not just our lives but our way of life.

 

INFORMATION OVERLOAD

Don’t know about you but the more I struggle to keep on top of all the corona news the more I feel I am drowning in a tsunami of information, even if at times it should be easy to discard – such as when we are repeatedly told that this or that vital fact about the disease is simply not known yet.

I make no apology, though, for adding my totally inexpert view to all the speculation and evaluation. Call it my contribution to democratic discourse. And at least I can genuinely claim to have consulted a pretty vast range of knowledge and opinion in forming my perspective and bringing it to you. Like the proverbial iceberg, nearly all of it remains underwater, unseen in the fairly small number of links I have given. A full reference list would run to well over a hundred articles and papers, to say nothing of broadcasts, podcasts, blogs etc., and many of these run to thousands of words, plus graphs, charts and hours of dialogue in sources such as The Economist, The Financial Times and Science, all of which have been among many serious sources giving free access to their Covid coverage, plus non-MSM alternatives such as Off-Guardian, Medium and Swiss Propaganda Research – thank you, “Explorer”, for alerting me to this last one. The MSM daily press in the UK and US have also been indispensible, plus quality periodicals such as The Spectator, and New Statesman on this side of the Atlantic and, well, The Atlantic on the other side.

With so much coverage to draw on, generally of high quality from both MSM and elsewhere, it is tempting to start an awards list here, my own personal Oscars for Best Statistical Presentation, Best Historical Parallels, etc. The ceremony could go on for hours, until you are all dropping like flies, killed not by Covid but boredom!

So I will refrain from that, or at least keep it short. I really absolutely must give a shout-out for UnHerd, especially the wonderful series of articles and podcasts on Sweden by executive editor Freddie Sayers. And I stick with Sweden for my two other nominations. The man I dubbed Heretic TOC’s “Europe Correspondent” after he told us about his encounter some time ago with Greta Thunberg, has been keeping up the good work with detailed, insightful on-the-spot reports for me from Sweden. Then, finally, I should mention the sterling contribution of Claire Fox’s Academy of Ideas, which recently hosted the first Zoom event in which I have participated, called “Economy Forum: How can we escape a coronavirus depression?” One of the speakers was Joan Hoey, director for Europe with the fabled Economist Intelligence Unit. I was able to ask her directly about the situation in Sweden. A full audio recording of this event is available for anyone interested.

 

Now we are truly ‘all in it together’

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At least they aren’t calling it the gay plague, the way they did with AIDS, or God forbid the paedo plague – they blame us kind folk for everything else, though, so why not the corona virus disease (Covid-19) first identified last December in China?

But stigmatisation of some sort follows closely on the heels of every pathogen, as was observed recently in the authoritative New England Journal of Medicine (NEJM). At first the finger was pointed, quite rightly, at Chinese “wet markets”, but this quickly morphed online into generalised anti-Asian racism. Within the last week, though, the demonization has moved closer to home: escaping into the open countryside to enjoy the fresh Spring air and sunshine is suddenly seen as selfish and anti-social. How weird is that?

Not so weird as to be completely irrational, apparently. The logic of ordering us all to stay at home is questionable but this is not a time for mutiny. That is because in this crisis we really are “all in it together”: we are affected not just as kinds, or MAPs, but simply as people. This thing is menacing everyone. It is time remind ourselves that although we at Heretic TOC are an awkward bunch of political heretics and sexual “deviants”, we are first and foremost humans; we need to make common cause with our fellows and acquit ourselves well.

Just to keep things in perspective: latest official statistics (ONS) weekly deaths data (to w/e 13 March) shows death numbers remain a bit lower than usual so far this year. In the year to date there have been 4% fewer deaths than the five-year average, as was pointed out in a recent tweet by a certain Stuart McDonald. It is presumably more than coincidental that there is a leading actuary of this name at Lloyds Banking Group.

So I will be doing my best to stick to the tough new rules for at least as long as I can be persuaded they are roughly in line with the best medical and scientific advice available to government. For Heretic TOC readers in the US, of course, that emphatically will not mean taking President Trump’s word for anything. In the UK, too, the prime minister may be blown off course by political winds. For the moment, though, to be blunt about it, this a time for obeying orders.

As the PM’s broadcast to the nation in the UK this week made clear, that means staying at home for everything except shopping for food and other basic needs, taking very limited exercise close to home, and working away from home only for those in “essential” occupations. These tough restrictions appear to have been imposed reluctantly by Boris Johnson who, we are told, is by instinct a social liberal rather than an authoritarian. All the more reassuring, then, that if even he feels draconian measures are required then there is good reason to believe they are necessary.

That said, this blog does not carry the responsibility that governments must take for their emergency laws and guidance advice. It is no part of the new rules nor of HTOC’s stated mission that this blog must stay “on message”. On the contrary, in common with the media at large, it could almost be said we have a duty to keep our critical faculties alert and challenge government policy if it doesn’t seem to make sense. A couple of commentators at HTOC have already begun to express unease over the opportunity the crisis presents for the illegitimate extension of state control in our lives. I am not going to focus on this danger but neither will I make light of it. Instead I will just urge everyone here, even if you visit none of my other links today, to read Anne Appelbaum’s chillingly informative article in The Atlantic on how a number of governments in Europe and elsewhere are already abusing the situation big-time.

While sexual ethics and behaviour might seem less important right now than hand-washing and social distancing, they do point to a serious shortcoming in any public health strategy that relies on stopping people doing what they really, really want to do, for months on end, or longer. As the NEJM article linked above notes, “Syphilis, one of the great scourges of the early 20th century, could have been ended, in theory, had everyone adhered to a strict regimen of abstinence or monogamy. But as one U.S. Army medical officer complained in 1943, ‘The sex act cannot be made unpopular.’” Likewise, even AIDS failed to eliminate risky unprotected sexual behaviour; it took the advent of antiretroviral therapy to stop that pandemic in its tracks. Getting out and chatting in bars and restaurants, taking part in sport or gathering in huge stadiums to watch it, going to clubs and concerts and a myriad other social activities are all acts which, just like sex “cannot be made unpopular”. Socialising, and simply getting outdoors, are human needs that cannot be suppressed for long.

And you know what, despite Donald Trump being wrong most of the time, he actually had a point this week when he said the cure could be worse than the disease when it comes to shutting down the economy to enforce social isolation. Sure, he only made that claim out of naked self-interest based on “it’s the economy, stupid”. He had been pinning his re-election hopes on a roaring stock market bull run, strong economic growth and full employment, all of which are now well down the toilet, especially on the vital jobs front, with over three million laid off in the US in a single week.

Trump was talking out of his ass and lying through his teeth, as usual, but his “thinking” is in line with the findings of a new study by Philip Thomas, professor of risk management at Bristol University.

If the coronavirus lockdown leads to a fall in GDP of more than 6.4% more years of life will be lost due to recession than will be gained through beating the virus, the study suggests. As reported in The Times, Thomas tells us that keeping the economy going in the next year will be crucial, otherwise the measures would “do more harm than good”. His own full report is all equations, graphs and figures, but the nature of the connection between recession and mortality was spelt out elsewhere in an IMF research paper, The Human Cost of Recessions, that appeared in 2010, after the Great Recession of 2007–09. This showed that in the short run layoffs are associated with higher risk of heart attacks and other stress-related illnesses. Anxiety, depression and an elevated suicide rate form the psychological background to this bleak picture. Even in the long term, the mortality rate of laid-off workers stays at a raised level and can persist for decades. What’s worse, the suffering is passed down to the next generation: children are hurt:

… children of laid-off parents also suffer: in the short-run, parental job loss tends to reduce the schooling achievement of their children….parental job loss increases the probability that a child repeats a grade in school by nearly 15 percent… In the long-run, a father’s income loss also reduces the earnings prospects of his sons… children whose fathers were displaced have annual earnings about 9% lower than similar children whose fathers did not experience an employment shock.

What we do not yet have figures for is the human cost of cooping people up in their homes. But we know what is bound to happen. We know that modern family life typically lacks the social support available to the extended families of old. The less well off, especially, confined to cramped houses and flats without even a decent garden for the kids to run about in, are at high risk of getting on each other’s nerves. Violent domestic abuse is rife even in the best of times and is bound to be a sharply ramped up danger when parents can no longer go out to work and their offspring cannot go to school either. This is a nuclear family under immense pressure, primed for explosion.

Bearing in mind the immense social costs of bringing the economy and ordinary life to a juddering halt  – to say nothing of the trillions of dollars needed to support all those who have been suddenly deprived of a livelihood in the lockdown countries – we really do need to question whether the whole strategy is truly necessary. The Netherlands doesn’t think so. Neither does Sweden. The UK, too, initially appeared to favour – on scientific advice – a policy of keeping ordinary life going for as long as possible consistent with keeping hospital cases down to a level that would not overwhelm health services and incur excessive danger to medical staffs. Making the call as to how long a lockdown could be reasonably avoided was always going to be a very sophisticated and difficult one, drawing on epidemiological models that inevitably include dubious assumptions – it could hardly be otherwise given the unknown properties of  the novel virus causing Covid-19, known as SARS-CoV-2.

But it was arguably an increasingly well established property of SARS-CoV-2 that must have been giving policy makers the biggest headache – a property with a moral dimension and huge political ramifications. I mean, of course, the fact that fatalities are almost entirely confined to those who already have very serious health problems, especially those who are very old and who even in normal times would not be expected to live much longer.

Statistics guru David Spiegelhalter tells us COVID-19 very roughly contributes a year’s worth of risk of dying. Every year around 600,000 people die in the UK. It has been estimated that if the virus went completely unchallenged, around 80% of people would be infected and there would be around 510,000 deaths. So getting COVID-19 is like packing a year’s worth of risk into a week or two. Which is why it is important to spread out the infections to avoid the NHS being overwhelmed. The graph compares Covid-19 mortality and ‘normal’ annual mortality. It shows the dramatic increase with age, and the small excess risk from Covid-19 for people in their 60s and 70s.

The unspeakable elephant in the room here is whether wrecking the economy at astronomic financial and devastating social cost is a good idea just to secure a bit of extra time on earth for clapped out old codgers, many of whom are bound to be rotting away miserably in old folks homes wishing they were dead anyway. Admittedly this is a sentiment a callous young neo-Nazi might heartily endorse but I speak as an old codger myself – no “underlying conditions” as yet, but I am in my mid-seventies, hence in the officially “vulnerable” age range. I value my own life, but I also feel it is reasonable to balance my hopes and expectations for my (probably quite short) future against the disasters that lockdown could bring, as we have seen.

This balancing act is no different, really, from the kind of utilitarian calculation being made every day by health service agencies such as Britain’s National Institute for Health and Care Excellence (NICE). NICE routinely provides evidence-based evaluations of cost effectiveness in relation to drugs being considered for use by the NHS. Often it has to take the not-at-all-nice but very necessary view that a life-saving drug is simply too expensive. Some patients will die as a result of the NHS not buying and providing it. But the judgement is that the money could be better spent elsewhere in the NHS, with the potential to save more lives than would be lost by refusing to approve a very expensive drug.

If you are still in doubt about the need for brutal utilitarian calculations of this sort, and if you cleave to the view that all lives are equally valuable, just try the following thought experiment. What if, instead of killing only old or sick people, SARS-CoV-2 was instead killing only children? Would you seriously insist that this was not a more serious problem? If such a disease had a high rate of mortality, it could even threaten the survival of our species, making the actual SARS-CoV-2 look quite a benign little beast by comparison. Short of that apocalypse, though, the main point surely is that any disease that kills children is one that deprives them of many years – decades even – of expected life ahead of them. So the “brutal” calculation is not a matter of disrespect for the elderly and infirm. If we think in terms of saving not “lives” but “expected years of life”, then saving children would still be heavily favoured over saving the elderly – if harsh reality forces us to choose – while according equal value to everyone’s future life.

And for ourselves, let’s be honest. Much as we might love our grandparents or (in my case) old pals of my own age, our delight in children is such that their loss would be devastating far beyond that of any other medical calamity. Nor are we alone in that feeling: “our” delight is not a feeling confined those of us who find kids especially exciting: it extends to ordinary parents and many other adults who are lucky enough to appreciate their charms.

I’d better leave it there, I think. There is so much more to discuss on what has rapidly become a news story with a thousand angles – I would love, for instance, to get into why the UK and other European governments were so ill-prepared compared to many of those in Asia, why experts were talking about “herd immunity”, and what Boris Johnson was trying to get across with his colourful “squashing the sombrero” metaphor. Basically, the latter was about delaying infections as much as possible so that cases occur over a long period and health systems aren’t suddenly inundated: slowly building herd immunity without killing a shielded vulnerable minority has been seen as a useful by-product of that strategy. It is complicated though. Anyway, there will be time to thrash things out in comments if y’all are up for it. In lieu of getting deeply into these angles at the moment myself, I would just recommend an article by Richard Horton, editor of The Lancet medical journal, in The Guardian on all the practical delay and policy confusion.

 

DO AS WE SAY, NOT AS WE DO

Rumours that a cart has been trundled along Downing Street by a refuse disposal officer crying “Bring out your dead!” may be apocryphal, but the news yesterday that Prime Minister Boris Johnson, Health Secretary Matt Hancock and Chief Medical Officer Chris Whitty had all gone down with corona virus at the same time is a powerful indication that the plague has struck hard at the heart and (cough, cough!) lungs of government.

Even more than the rest of us, the governing elite are showing themselves to be all in it together, united in their evident unwillingness or inability to follow the precautions they have urged upon the rest of us. Scenes from parliament quite recently, for instance, showed MPs crowding around the Speaker’s chair, blithely ignoring the two-metre social distancing rule. Hardly surprising, then, that Westminster as well as Whitehall has emerged as the UK’s outbreak epicentre, our very own wet market, teeming with slimy, slippery specimens. Among those who have been stricken, along with his girlfriend, Spectator writer Isabel Hardman, is my treacherous former (Labour) MP John Woodcock. One of his lesser crimes was to get me kicked out of the Labour Party. His most heinous offence, though, was at the last election, when he advised his former constituents to vote Tory. In all honestly, I am not exactly shedding tears over his affliction. Like the pestilential visitations of old, it is obviously in his case a sign of God’s displeasure!

One final recommendation, if you have a moment: Tom Peck, political sketch writer for The Independent, takes a butcher’s at “what happens when you ignore your own advice”. It’s a satirical gem on the current hand-washing-with-soap opera. Come to think of it, how about a new TV soap: Corona-nation Street, perhaps, or Westminster Deadenders? Nah, the real political scene is much more entertaining!

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