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Spread & Containment

More testing means more iceberg

More testing means more iceberg



COVID-19 case numbers are rising quickly in many parts of the northern hemisphere. Already some totals have outstripped the peaks seen in the first wave of the pandemic. Europe and The United States, in particular, look to be in for a harsh winter. As we look at testing and hospital outcomes, we can see reasons for why wave 2 looks different from wave 1 (if wave 1 ever truly finished) in March/April. In particular, we often see just the tip of the iceberg when it comes to outbreaks and epidemics. But in wave 2 more testing means more iceberg is in view.

Initial testing shock

One thing is pretty clear; laboratories and biotechnology companies worldwide were unprepared for the scale of a pandemic. This wasn’t a slow-moving SARS-CoV or a poorly transmitting MERS-CoV. This was a fast-moving, fully armed, well-equipped, respiratory virus. Labs couldn’t keep pace. And even though test development was super-quick, the fuel to feed and power what those tests needed, quickly became scarce.

Despite the lab challenges posed by Ebola virus epidemics in Africa just a few years ago, and Zika virus epidemics across the world, testing wasn’t ready enough for pandemic 2020. In today’s world, a pandemic was always going to mean using real-time PCR-based tools to detect the virus. These were the most sensitive tests we had. Also, we didn’t have a better tool because no replacement had hit the mainstream. Despite the recurring promise of new platforms pitched during recent outbreaks and epidemics, PCR hasn’t faced a mainstream challenger since it’s real-time iteration hit the brights lights in 2009.

After COVID-19 worldwide wave 1, sample throughput increased although turnaround times still seem to blow out whenever cases rise quickly. The improvements have meant that we no longer just see just the “tip of the iceberg“, but much more of what lies beneath the waterline.

NOTE: After the initial spread of the last (influenza) pandemic and in every annual flu epidemic, we seek to test only a portion of cases – usually those who are sick – to get a good idea of how much and which viruses are around. In this pandemic we’re trying to test more than that. We’ve asked more from our testing than ever before, and it’s not clear that our pandemic plans ever suggested we do that, which may be why lab capacity planning may have suffered. One major reason for all this testing is so that we can contact trace and then quarantine and isolate to interrupt transmission. In some countries, however, tracing isn’t functioning because there is an overwhelming number of cases. Tetsing without a follow-up action is perhaps a poor use of resources. Once we can protect the vulnerable with vaccines and treat COVID-19 with useful and specific antivirals, the need for extensive tetsing will probably recede.

The tip of the iceberg

You’ve probably heard that phrase a million times; the “tip of the iceberg”. It’s used during outbreaks to remind us that we only ever detect and record some of the infections due to a pathogen; usually, the easiest ones to find and test. The comparison is to the iceberg; we only see that small piece of the whole which protrudes above the waves.

The graphic demonstrates this for COVID-19. Initially, we only tested those people linked to travel from China and close contacts, then those with pneumonia then we moved to test local hotspots, those in hospital, and eventually, we started testing anyone with symptoms and some without (for contact tracing or to gauge the level of asymptomatic versus presymptomatic transmission), even coming to your street to test. Now we know that its possible to find SARS-CoV-2 in those with a range of symptoms – which means we are seeing more of COVID-19 (the iceberg).

A beautiful visualization of the combination and permutations of signs and symptoms in patients infected with SARS-CoV-2.
From Australia’s COVID-19 fortnightly epidemiology report No. 25.

The infographic above also includes what we currently consider to be the COVID-19 infection fatality ratio (IFR). The IFR is the percentage of deaths due to COVID-19 among all cases, not just those that were tested through relative convenience.

The case fatality ratio (CFR) however, is more simply the number of deaths divided by the number of cases (usually presented once everyone’s infections have run their course).

The CFR doesn’t include real infections that were missed because they were mild, or asymptomatic or those people just weren’t tested. The IFR tries to capture all of these.

A blanket IFR value (“point estimate”) was recently calculated to be 0.68%.[5] But it doesn’t seem like it;s that low when you look over the numbers.

In the US, the CFR was, at the time of writing, 2.6%.[6] That is 3.8x higher than the global IFR estimate.

Among other things, that higher value hints that there still isn’t enough testing in the US, even though they’re doubling their target of 500,000 tests per day.[7]

NOTE: If we drill down in the US to look at CFRs in different States (or further within States), you’d see all sorts of variation.[8] Wisconsin is at 0.86%, California at 2.1%, Washington at 2.2%, New Hampshire at 4.6%, New York State at 6.7% and New Jersey at 7.1%. This is just a reminder that any given jurisdiction tells it’s own unique COVID-19 tale. Comparing different people and places is not straightforward.

More testing means more iceberg

As testing has increased so too has the denominator for CFR calculations – that number at the bottom of the fraction below.

Here the denominator is TOTAL COVID-19 cases (lab-confirmed positives). If we can assume we’re as good at capturing the hospitalised and seriously ill COVID-19 cases now as we were during wave 1, but now we’re adding more of the milder illnesses to the denominator because more testing is available, then the CFR will decrease. Also, the time between diagnosis and death may now look more delayed (I’ll explain below) than it was earlier in the year. We may already be seeing this extra lag in our line graphs and bar charts.

A newly shaped iceberg?

Lag? What I mean is the delay between diagnosis and death in those who go on to succumb to severe disease. Right now, we’re not seeing deaths rising the way they did in wave 1.

This graph is plotted in a way that shows that deaths (bars extending below the horizontal axis) lag diagnoses (bars extending above the horizontal axis) by weeks. The axes use different values, to make the rising death curve clear.
Source: An example from Twitter by Marc Bevand

Using another nice example from Twitter by Marc Bevand we see a major reason why we’re only just starting to view an upturn in death curves among northern hemisphere countries, despite cases rising for weeks. Both the shape and size of the curve have likely changed because of all the extra testing. If you look at the blue curve for Spain below, you can see that it is predicted to start rising earlier than what was charted at the time.

The height and the width of the base of the case curve has likely changed between wave 1 and wave 2. This is an attempt to exemplify that change. We may have seen a bigger lag between rapid rise in diagnoses and deaths during wave 1, if more testing was in place back then to capture more of the iceberg earlier on.
Source: An example from Twitter by Marc Bevand

If we were conducting the degree of testing back in March/April that we are now, it might have taken longer to visualise a rise in deaths then as well. We’ve improved our capture of the 80% of COVID-19 we’d expect to find outside of a hospital. We’d become used to a two to five-week lag (predicted to be up to 11 weeks by Marc).

The message here is: don’t get too comfortable with what appears to be a changed pattern where cases are rising but deaths are not. Wait a bit longer than before.

NOTE: those mutterings that SARS-CoV-2 is less virulent? They aren’t supported by any solid evidence right now and I’m not sure they will be anytime soon. Let’s nail that to the pile of “wishful thinking” that has plagued the response to this pandemic.

Beyond the idea that more testing means more iceberg, there have been some other changes as the first wave receded – like the use of the steroid dexamethasone to reduced the 28-day mortality rate by 17% [15,16] and prone positioning to aid oxygenation (although not survival [18) in adult pneumonia patients.[17] These changes have contributed to less severe disease and fewer deaths and should continue to do so going forward.

The COVID-19 death rate dropped a little aswave 1 progressed

Two new studies observed this. Deaths across all age groups decreased as the first wave progressed. But exactly why isn’t known.[1,2,3] Some thoughts from the authors below.

Thinking of England

In a study of national English adult COVID-19 critical care admissions, the authors saw reductions in death regardless of age (three age bands examined), sex or ethnicity (“white” or “Asian”). They also saw a drop when they looked at diabetes and kidney disease but not when looking at those with chronic respiratory disease, between March and May.[2]

The authors noted that bed saturation was highest in April which may have made individual patient management much harder. This really makes the point that if you don’t flatten the curve, you can create a situation where more death and severe disease occurs than expected.[2]

Bright lights, big city

Among an analysis of 4,689 hospitalisations in New York City between March and June, the median age and the proportion of males with underlying disease decreased.[1] But this didn’t fully explain a reduction in mortality over the study period.

Interestingly the amount of viral RNA being detected in each case also decreased. The authors had quite a list of factors which they suggest each may have added to the improved outcomes:

  • decreased bed saturation
  • increased use of corticosteroids, Remdesevir and anti-cytokine drugs
  • earlier intervention
  • community awareness
  • mask-wearing resulting in exposure to a lower viral dose

A grim winter may lie ahead for the north

Despite this good looking news, don’t celebrate yet. So far we’ve learned that more testing has probably changed the pattern we got used to during the first surge of COVID-19; more testing means more iceberg. But if hospitals get overwhelmed, deaths will happen in greater than predicted numbers. This is a trajectory that some countries in the northern hemisphere are already on unless they take more action. It may already be too late for tinkering around the edges and lockdowns may be the only way forward.

Rapidly rising case numbers: deaths will follow

Tragically, as if we are living in a time loop, COVID-19 cases are once again steeply rising across Europe and in the United States, which the hasn’t seen case numbers drop below 13,000 per day () since late March.

For reasons such as those we’ve discussed above, deaths may not yet be doing what we saw in the first half of 2020. But hospital bed saturation is again rising and thus bed capacity is falling.[4] More testing means more iceberg, but even if there is a greater lag, death follows more COVID-19 hospitalizations which are increasing in multiple countries across the northern hemisphere.[9,10,11,12,13,14,15]

It’s imperative more is done to stop the spread of COVID-19 but it has to be done quickly. More cases today is a window into what happened up to two weeks ago. More cases today also means more deaths in the ensuing months. That’s a given. How many deaths and how quickly numbers rise, remains to be seen.

Things we can do about this

We can each take personal responsibility for our health and that of those around us. We can abide by rules ad mandates. We can listen to experience, learning from and acting on what’s worked in other parts of the world; avoiding what hasn’t worked. We can squash false hopes and put aside wishful thinking. We need to seek out reality – harsh though it may be – and we should strangle misinformation and promote facts.

We can each do these things. We can do them together too.

Meanwhile, our governments can show the leadership we expect by organising and providing what’s required to address the shared responsibilities section in the infographic below. Including encouragement and financial and mental health support for the community to stay home. And on that point – if your government isn’t leading you to a healthier safer future then vote, and choose to replace it with a better government when next you get that chance. There are things we can do.


  1. Trends in Covid-19 risk-adjusted mortality rates in a single health system
  2. Improving COVID-19 critical care mortality over time in England: A national cohort study, March to June 2020
  3. Studies Point To Big Drop In COVID-19 Death Rates
  4. ‘It is terrifying’: WHO sounds alarm as daily infections in Europe more than double in 10 days
  5. A systematic review and meta-analysis of published research data on COVID-19 infection-fatality rates
  6. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University
  7. COVID Exit Strategy website
  8. Covid in the U.S.: Latest Map and Case Count
  9. US hospitals are preparing for the worst-case scenario as Covid-19 surges again
  10. U.S. sees highest number of new COVID-19 cases in past two days
  11. France sees highest number of Covid-19 patients going into hospital since April
  12. Coronavirus cases in Spain top one million as pandemic accelerates
  13. Dutch hospital airlifts patients to Germany amid virus surge
  14. Switzerland faces lack of hospital beds as coronavirus infections soar
  15. Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report
  16. Covid-19: Low dose steroid cuts death in ventilated patients by one third, trial finds
  17. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study
  18. Effect of Prone Positioning on the Survival of Patients with Acute Respiratory Failure

Hits: 11

The post More testing means more iceberg appeared first on Virology Down Under.

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Spread & Containment

Las Vegas Strip faces growing bed bug problem

With huge events including Formula 1, CES, and the Super Bowl looming, the Las Vegas Strip faces an issue that could be a major cause for concern.



Las Vegas beat the covid pandemic.

It wasn't that long ago when the Las Vegas Strip went dark and people questioned whether Caesars Entertainment, MGM Resorts International, Wynn Resorts, and other Strip players would emerge from the crisis intact. 

Related: Las Vegas Strip report shares surprising F1 race news

In the darkest days, the entire Las Vegas Strip was closed down and when it reopened, it was not business as usual. Caesars Entertainment (CZR) - Get Free Report and MGM reopened slowly with all sorts of government-mandated restrictions in place.

The first months of the Strip's comeback featured temperature checks, a lot of plexiglass, gaming tables with limited numbers of players, masks, and social distancing. It was an odd mix of celebration and restraint as people were happy to be in Las Vegas, but the Strip was oddly empty, some casinos remained closed, and gaming floors were sparsely filled. 

When vaccines became available, the Las Vegas Strip benefitted quickly. Business and international travelers were slow to return, but leisure travelers began bringing crowds back to pre-pandemic levels. 

The comeback, however, was very fragile. CES 2022 was supposed to be Las Vegas's return to normal, the first major convention since covid. In reality, surging cases of the covid omicron variant caused most major companies to pull out.

Even with vaccines and covid tests required, an event that was supposed to be close to normal, ended up with 25% of 2020's pre-covid attendance. That CES showed just how quickly public sentiment — not actual danger — can ruin an event in Las Vegas.

Now, with November's Formula 1 Race, CES in January, and the Super Bowl in February all slated for Las Vegas, a rising health crisis threatens all of those events.

The Arena Media Brands, LLC and respective content providers to this website may receive compensation for some links to products and services on this website.

Covid left Las Vegas casinos empty for months.

Image source: Palms Casino

The Las Vegas Strip has a bed bug problem   

While bed bugs may not be as dangerous as covid, Respiratory Syncytial Virus (RSV),  Legionnaires’ disease, and some of the other infectious diseases that the Las Vegas Strip has faced over the past few years, they're still problematic. Bed bugs spread easily and a small infestation can become a large one quickly.

The sores caused by bed bugs are also a social media nightmare for the Las Vegas Strip. If even a few Las Vegas Strip visitors wake up covered in bed bug bites, that could become a viral nightmare for the entire city.

In late-August, reports came out the bed bugs had been at seven Las Vegas hotel, mostly on the Strip over the past two years. The impacted properties includes Caesars Planet Hollywood and Caesars Palace as well as MGM Resort International's (MGM) - Get Free Report MGM Grand, and others including Circus Circus, The Palazzo, Tropicana, and Sahara.

VISIT LAS VEGAS: Are you ready to plan your dream Las Vegas Strip getaway?

"Now, that number is nine with the addition of The Venetian and Park MGM. According to the health department report, a Venetian guest reported seeing the bloodsuckers on July 29 and was moved to another room. An inspection three days later confirmed their presence," reported.

The Park MGM bed bug incident took place on Aug. 14.

Bed bugs remain a Las Vegas Strip problem

Only Tropicana, which is soon going to be demolished, and Sahara, responded to about their bed bug issues. Caesars and MGM have not commented publicly or responded to requests from KLAS or

That makes sense because the resorts do not want news to spread about potential bed bug problems when the actual incidents have so far been minimal. The problem is that unreported bed bug issues can rapidly snowball.

The Environmental Protection Agency (EPA) shares some guidelines on bed bug bites on its website that hint at the depth of the problem facing Las Vegas Strip resorts.

"Regularly wash and heat-dry your bed sheets, blankets, bedspreads and any clothing that touches the floor. This reduces the number of bed bugs. Bed bugs and their eggs can hide in laundry containers/hampers. Remember to clean them when you do the laundry," the agency shared.

Normally, that would not be an issue in Las Vegas as rooms are cleaned daily. Since the covid pandemic, however, some people have opted out of daily cleaning and some resorts have encouraged that.

F1? SUPER BOWL? MARCH MADNESS? Plan a dream Las Vegas getaway.

Not having daily room cleaning in just a few rooms could lead to quick spread.

"Bed bugs spread so easily and so quickly, that the University of Kentucky's entomology department notes that "it often seems that bed bugs arise from nowhere."

"Once bed bugs are introduced, they can crawl from room to room, or floor to floor via cracks and openings in walls, floors and ceilings," warned the University's researchers.  



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Americans are having a tough time repaying pandemic-era loans received with inflated credit scores

Borrowers are realizing the responsibility of new debts too late.



With the economy of the United States at a standstill during the Covid-19 pandemic, the efforts to stimulate the economy brought many opportunities to people who may have not had them otherwise. 

However, the extension of these opportunities to those who took advantage of the times has had its consequences.

Related: American Express reveals record profits, 'robust' spending in Q3 earnings report

Credit Crunch

GLASTONBURY, UNITED KINGDOM - JANUARY 12: In this photo illustration the Visa, Mastercard and American Express logos are seen on credit and debit cards on March 14, 2022 in Somerset, England. Visa, American Express and Mastercard have all announced they are suspending operations in Russia and credit and debit cards issued by Russian banks will no longer work outside of the country. (Photo by Matt Cardy/Getty Images)

Matt Cardy/Getty Images

A report by the Financial Times states that borrowers in the United States that took advantage of lending opportunities during the Covid-19 pandemic are falling behind on actually paying back their debt.

At a time when stimulus checks were handed out and loan repayments were frozen to help those affected by the economic shock of Covid-19, many consumers in the States saw that lenders became more willing to provide consumer credit.

According to a report by credit reporting agency TransUnion, the median consumer credit score jumped 20% to a peak of 676 in the first quarter of 2021, allowing many to finally have “good” credit scores. However, their data also showed that those who took out loans and credit from 2021 to early 2023 are having an hard time managing these debts.

“Consumer finance companies used this opportunity to juice up their growth at a time when funding was ample and consumers’ finances had gotten an artificial boost,” Chief economist of Moody’s Analytics Mark Zandi told FT. “Certainly a lot of lower-income households that got caught up in all of this will feel financial pain.”

Moody’s data shows that new credit cards accounts that were opened in the first quarter of 2023 have a 4% delinquency rate, while the same rate in September 2022 was 4.5%. According to the analysts, these levels were the highest for the same point of the year since 2008.

Additionally, a study by credit scoring company VantageScore found that credit cards issued in March 2022 had higher delinquency rates than cards issued at the same time during the prior four years.

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Credit cards were not the only debts that American consumers took on. As per S&P Global Ratings data, riskier car loans taken on during the height of the pandemic have more repayment problems than in previous years. In 2022, subprime borrowers were becoming delinquent on new cars loans at twice the rate of pre-pandemic levels.

S&P auto loan tracker Amy Martin told FT that lenders during the pandemic were “rather aggressive” in terms of signing new loans.

Bill Moreland of research group BankRegData has warned about these rising delinquencies in the past and had recently estimated that by late 2022, there were hundreds of billions of dollars in what he calls “excess lending based upon artificially inflated credit scores”.

The Government's Role

WASHINGTON, DC - APRIL 29: U.S. President Donald Trump's name appears on the coronavirus economic assistance checks that were sent to citizens across the country April 29, 2020 in Washington, DC. The initial 88 million payments totaling nearly $158 billion were sent by the Treasury Department last week as most of the country remains under stay-at-home orders due to the COVID-19 pandemic. (Photo by Chip Somodevilla/Getty Images)

Chip Somodevilla/Getty Images

Because so many are failing to pay their bills, many are wary that the government assistance may have been a financial double-edged sword; as they were meant to alleviate financial stress during lockdown, while it led some of them to financial difficulty.

The $2.2 trillion Cares Act federal aid package passed in the early stages of the pandemic not only put cash in the American consumer’s pocket, but also protected borrowers from foreclosure, default and in some instances, lenders were barred from reporting late payments to credit bureaus.

Yeshiva University law professor Pam Foohey specializes in consumer bankruptcy and believes that the Cares Act was good policy, however she shifts the blame away from the consumers and borrowers.

“I fault lenders and the market structure for not having a longer-term perspective. That’s not something that the Cares Act should have solved and it still exists and still needs to be addressed.”

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Inflation: raising interest rates was never the right medicine – here’s why central bankers did it anyway

We need to start cutting rates, but there’s something that has to happen first.

Pain, no gain? Bank of England Governor Andrew Bailey. IMF, CC BY-SA

Inflation remains too high in the UK. The annual rate of consumer price inflation to September was 6.7%, the same as a month earlier. This is well below the 11.1% peak reached in October 2022, but the failure of inflation to keep falling indicates it is proving far more stubborn than anticipated.

This may prompt the Bank of England’s Monetary Policy Committee (MPC) to raise the benchmark interest rate yet again when it meets in November, but in my view this would not be entirely justified.

In reality, the rate hikes that began two years ago have not been very helpful in tackling inflation, at least not directly. So what’s the problem and is there a better alternative?

Right policy, wrong inflation

Raising interest rates is the MPC’s main tool for trying to get inflation back to its target rate of 2%. The idea is that this makes it more expensive to borrow money, which should reduce consumer demand for goods and services.

The trouble is that the type of inflation recently witnessed in the UK seems less a problem of excessive demand than because costs have been rising for manufacturers and service providers. It’s known as “cost-push inflation” as opposed to “demand-pull inflation”.

Inflation rates (UK, US, eurozone)

Graph comparing inflation rates of UK, US and eurozone
UK = dark blue; eurozone = turquoise; US = orange. Trading View

Production costs have risen for several reasons. During the COVID-19 pandemic, central banks “created money” through quantitative easing to enable their governments to run large spending deficits to pay for furloughs and other interventions to help citizens through the crisis.

When countries started reopening, it meant people had money in their pockets to buy more goods and services. Yet with China still in lockdown, global supply chains could not keep pace with the resurgent demand so prices went up – most notably oil.

Oil price (Brent crude, US$)

Chart showing price of Brent crude oil
Trading View

Then came the Ukraine war, which further drove up prices of fundamental commodities, such as energy. This made inflation much worse than it would otherwise have been. You can see this reflected in consumer price inflation (CPI): it was just 0.6% in the year to June 2020, then rose to 2.5% in the year to June 2021, reflecting the supply constraints at the end of lockdown. By June 2022, four months after Russia’s invasion of Ukraine, CPI was 9.4%.

The policy problem

This begs the question, why has the Bank of England (BoE) been raising rates if it’s unlikely to be effective? One answer is that other central banks have been raising rates. If the BoE doesn’t mirror rate rises in the US and eurozone, investors in the UK may move their money to these other areas because they’ll get better returns on bonds. This would see the pound depreciating against the US dollar and euro, in turn increasing import prices and aggravating inflation.

Part of the problem has been that the US has arguably faced more of the sort of demand-led inflation against which interest rates are effective. For one thing, the US has been less at the mercy of rising energy prices because it is energy self-sufficient. It also didn’t lock down as uniformly as other major economies during the pandemic, so had a little more space to grow.

At the same time, the US has been more effective at bringing down inflation than the UK, which again suggests it was fighting demand-driven price rises. In other words, the UK and other countries may to some extent have been forced to follow suit with raising interest rates to protect their currencies, not to fight inflation.

What next

How harmful have the rate rises been in the UK? They have not brought about a recession yet, but growth remains very weak. Lots of people are struggling with the cost of living, as well as rent or mortgage costs. Several million people are due to be hit by much higher mortgage rates as their fixed-rate deals end between now and the end of 2024.

UK GDP growth (%)

Chart showing the annual rate of GDP growth
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If hiking interest rates is not really helping to curb inflation, it makes sense to start moving in the opposite direction before the economic situation gets any worse. To avoid any damage to the pound, the answer is for the leading central banks to coordinate their policies so that they cut rates in lockstep.

Unless and until this happens, there would seem to be no quick fix available. One piece of good news is that the energy price cap for typical domestic consumption was reduced from October 1 from £1,976 to £1,834 a year. That 7% reduction should lead to consumer price inflation coming down significantly towards the end of 2023.

More generally, the Bank of England may simply have to hope that world events move inflation in the desired direction. A key question is going to be whether the wars in Ukraine and Israel/Gaza result in further cost pressures.

Unfortunately there is a precedent for a Middle East conflict leading to a global economic crisis: following the joint assault on Israel by Syria and Egypt in 1973, Israel’s retaliation prompted petroleum cartel OPEC to impose an oil embargo. This led to an almost fourfold increase in the price of crude oil.

Since oil was fundamental to the costs of production, inflation in the UK rose to over 16% in 1974. There followed high unemployment, resulting in an unwelcome combination that economists referred to as stagflation.

These days, global production is in fact less reliant on oil as renewables have become a growing part of the energy mix. Nonetheless, an oil price hike would still drive inflation higher and weaken economic growth. So if the Middle East crisis does spiral, we may be stuck with stubborn, untreatable inflation for even longer.

Robert Gausden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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