As an epidemiologist and doctor who volunteered to return to the frontline in both waves, I have seen first hand the death and suffering from Covid. And, also, the knock-on effects on those affected by cancelled services. Deciding when to end lockdown is, of course, a difficult decision, but I now fear the costs of lockdown will soon start beginning to outweigh the benefits.
There is no doubt that Covid-19 has the capability to rapidly overwhelm our healthcare system and cause unprecedented casualties. Indeed, what has transpired over the last year suggests that Neil Ferguson’s figure – that the virus was capable of taking 500,000 lives – looks fairly accurate. Covid clearly had to be suppressed to stop the NHS being overrun and to keep all emergency services running.
That does not change the fact, however, that the harms of lockdown are grave, from the loss of education to increased unemployment, to tolls on people’s mental and physical health. The timing of lifting restrictions should be based on our best estimate of when particular restrictions are likely to start causing more harm than benefit. Finding the balance is no easy feat. This is not least, in-part, because cost-benefit analyses and impact assessments have limitations and are subject to significant uncertainties (as are the imperfect models which have been used to make policy decisions). But they still provide the best means of establishing whether an intervention is likely to cause more benefit than harm.
In July, the government published a comprehensive health cost-benefit analysis showing that, in the very long-term, the health impacts of the two month lockdown last year and lockdown-induced recession were greater than those of the direct Covid-19 deaths – although the difference was very small. This is why I had been very keen to avoid further lockdowns unless there was a material risk of the NHS being overwhelmed – in which case the benefits of lockdown clearly outweighed the harms – which is why in the end, I did support them. I also recently realised that, in common with many other analyses, it had not distinguished between the health and economic harms caused by lockdown versus those of Covid itself. (The updated report has now corrected that mistake).
Even if Boris Johnson had not locked down, people would have stayed home and the economy would have been badly hit: as we have seen in Sweden and certain US states. When Covid rises above a certain level, people naturally change their behaviour to reduce their risk which effectively leads to a ‘voluntary lockdown’. This is a point made by the opponents of lockdown: that you can trust people to socially distance without sending the police after them.
Today, however, with the vaccine being rolled out, the benefits of lockdowns will start becoming more marginal. But the goalposts have been increasingly shifting. First, the aim was to protect the NHS and save lives. Now the worry about new variants appears to be driving some scientists, advisers and politicians towards a ‘Zero Covid’ strategy in all but name.
There is now an increasing push to keep restrictions in place until infections are at a very, very low level. This is a huge error, for it is simply not achievable. Case numbers will never get low enough to enable every case to be intercepted via Track and Trace. Some of the ‘safe’ thresholds being suggested are ludicrous. Independent Sage, for instance, suggested about 60 cases per day. The lowest we achieved in July last year was about 600: after nine weeks of lockdown and 13 weeks of restrictions.
Britain is also likely to start experiencing lockdown fatigue. We know that compliance is lower than in the first lockdown – and we can expect this to continue as people see cases fall and deaths plummet.
The blunt truth is that there is no realistic prospect of Covid-19 being eradicated globally or within mainland Europe – with whom we effectively share a land border through the Channel Tunnel. It is easy to forget, but every day, thousands of lorries go through delivering food and other essential supplies – we simply cannot quarantine every driver. Even if it were achievable, it is not desirable because the length of lockdown required in pursuing Covid elimination strategy will almost certainly cause more overall health harm than benefit – particularly once the threat that Covid poses drops significantly as the majority of people are vaccinated.
At the other extreme, we have those calling for no restrictions – regardless of the costs – although they are a small minority.
A more moderate position is to lift all restrictions when every high-risk group has received their first dose: the government says this will happen at the end of April. But it also has to be evident that this approach will not lead to the NHS being overwhelmed – when the costs will again outweigh the benefits – and we end up in a fourth lockdown. The current vaccination programme has holes: even if 90 per cent of people take the jab and they are 90 per cent effective, that leaves enough vulnerable people for cases to shoot up again if unlocking is not managed carefully. Even Israel, with all its vaccine success, has seen hospital admissions fall only slightly due to the virus spreading in younger age groups.
There is, however, a middle way, one which will minimise overall harm and also have broad scientific and public support. We should accept that we will need to live with the virus, forget about eradication and start lifting restrictions roughly every three weeks, as we assess the impact of the previous step. The aim should be to reach low (ie, Tier 1) restrictions three weeks after the over-50s have been vaccinated. The reopening of schools should not force cases back up (this didn’t happen when schools were opened in the November lockdown). Further stages of lockdown release will depend on whether hospital & ICU admissions continue to fall.
Even without vaccines, there was no resurgence of Covid cases or hospitalisations last summer (the R rate never reached more than 1.5). Of course some restrictions and measures remained in place to control virus spread (Britain had tighter restrictions last summer than any other European country apart from Portugal) but most rational people would be willing to accept the level of restrictions we had in August (Tier 1 style) when the economy made a good recovery and peoples’ mental health significantly improved.
Unlocking should not be based on arbitrary dates – but it should not be based on reaching an arbitrary number of cases either. Particularly as the whole point of vaccination is that it will significantly change the relationship between cases, hospital admissions and deaths.
We need to decide what the acceptable level of risk is; how much death we are prepared to accept. It is likely that with vaccination and better treatments, the number of deaths and hospital admissions from Covid could be no worse than flu – so how we respond to it needs to change as such.
The Prime Minister will, understandably, be wary on Monday of promising too much given previous false dawns. There are no easy solutions, just difficult trade-offs. But the extraordinary success of the vaccination program means that he can now temper his caution with optimism and provide a clear path out of lockdown.
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