Raghib Ali: Freedom Day – why not unlocking now means delaying indefinitely

19 Jul

Dr Raghib Ali is a Clinical Epidemiologist at the University of Cambridge and an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust.

With ‘Freedom day’ finally upon us, the government once again finds itself under fire from both sides – being simultaneously accused of unethical recklessness/a ‘let it rip’ strategy by some and excessive caution/a ‘zero Covid’ strategy by others.

Both accusations are wide off the mark for the reasons I outline below. There are sound scientific reasons to proceed with step four now – but with caution – and the Government needs to get the messaging right on this to maintain public confidence and maximise the benefits of step four while minimising its harms, and to ensure that we avoid a return to restrictions later in the year.

Aside from a small but vocal minority, most scientists accept that ‘Zero Covid’ is impossible and that Covid-19 will become an endemic disease, that we will have to learn to live with it, and that there must be a time when we will lift all restrictions. The only question really is when?

Because the Delta variant is so transmissible, and vaccines are not a hundred percent effective in reducing transmission, it’s likely to be impossible to reach herd immunity – whereby eventually everyone will become immune – either through infection or vaccination.

(Of course, the higher the proportion that are immune, the harder it is for the virus to spread – and so the UK is in a much better position than other countries with over 90 per cent of adults having antibodies due to a combination of extremely high levels of vaccine uptake in older age groups and natural infections in under 40s.)

An exit wave is therefore inevitable and every country will have one when they finally lift restrictions – including Australia and New Zealand. No country will be able to keep its borders closed forever.

The size of this wave is determined by the number of people who are not immune from vaccination or natural infection. And, once everyone who wants to take the vaccine has been offered it, that’s not going to be reduced significantly by waiting (particularly as the JCVI has not yet recommended vaccines for children). In short, future infections, hospital admissions and deaths are no longer being prevented, just postponed.

And although we are not quite there, the potential benefit of delay is now marginal – in contrast to the situation four weeks ago, when I backed a delay. All those at high risk of hospitalisation and death (i.e. over-40s) have had the opportunity to get both doses (and all adults, one dose) which is why a delay doesn’t reduce hospital admissions and death. Even for infections, the second dose in 18-40 year olds is unlikely to make as much difference as vaccine effectiveness is double that of over-40s for the delta variant.

(This may be due to a better immune response in younger people and also because this age group are most likely to have been previously infected and so their first dose acts more like a second dose.)

And there are some clear advantages of proceeding with step four now, with school holidays reducing the number of contacts and seasonal factors reducing viral transmission. It is better to have the exit wave when the most vulnerable have the highest levels of protection, as they do now. The value of booster doses is still unproven and uptake is uncertain so our defences from vaccination are now likely to be as strong as they will ever be.

As the CMO outlined last week, the modelling shows that all dates lead to similar outcomes for infections, hospital admissions, and deaths. Some models even show outcomes could be worse if step four is delayed to the Autumn due to seasonal factors and the NHS being under even greater pressure from other respiratory viruses including influenza (which is likely to be much worse this year due to people having less pre-existing immunity as there was almost no flu last year.)

The impact of Covid-19 on the NHS is of course something I am well aware of and we are undoubtedly under great pressure now (June was the busiest month ever for emergency departments) with high levels of sickness. But this pressure will not decrease in the coming months and may get worse – and so again, a delay does not help.

‘Long Covid’ is also a valid and important concern and vaccination does reduce it as it reduces infection. However, even if a delay could be shown to significantly reduce the burden of long Covid (which is uncertain) that still needs to be weighed against the health harms which would arise from ongoing restrictions, be that worsening mental health or unemployment.

The final concern relates to new mutations arising due to high prevalence of infection in a partially vaccinated population. But again once you have reached the vaccination uptake ceiling, this will happen whenever step four is taken.

So those who want to continue with restrictions should be honest with the public: that not opening now means delaying indefinitely.

Given all the above, some are understandably asking why caution and continued guidance are still required?

The main consistent finding shown by the various SAGE models showed that if everyone returned to their pre-pandemic behavior/number of contacts quickly (within one month) this could lead to very significant pressure on the NHS approaching that of the first wave (when it would again be difficult to maintain all services causing significant indirect health harm to all other patients and increasing waiting lists further). The peak is much smaller, however, if this happens over three months. This doesn’t reduce overall admissions but spaces them out – i.e. we are back to ‘flattening the peak.’

This is clearly not a zero Covid strategy, but is aiming to be a ‘flu strategy’. This makes sense now given the infection fatality ratio of Covid with our levels of vaccination is similar to flu, and society has been willing to accept that restrictions are not required for flu.

The key remaining uncertainties are the number of contacts people will return to (and how quickly) and the exact levels of vaccine effectiveness. If both of those are ‘worse’ than expected, it is possible that the NHS will come under such great pressure that restrictions will need to be re-introduced.

And that is why it is essential that viral spread is kept under some control through good public health messaging on the need to continue to follow the guidance and why the test, trace and isolate system is still needed (about a third of those who self-isolate go on to develop Covid-19 symptoms) for now while we work our way through this exit wave and cases start falling again.

In many ways,  this approach is similar to the plan I outlined last year when I thought vaccines may be years away and I advocated for mainly voluntary measures and a focus on personal responsibility, as this would lead to more sustainable compliance (especially with indoor household mixing and self-isolation) while reducing other health harms.

Since then, we have seen that people can be trusted to take personal responsibility for themselves and others and will choose the responsible course of action (e.g. over Christmas when contacts didn’t increase overall and polls now show that a large majority of people will continue to wear masks.) And as with previous waves, there are also already signs (from Google mobility / shopping data and so on) that people are changing their behaviour as cases increase.

Finally, it is important to stress that Covid is far from over and that while today is an important and necessary step towards freedom, with freedom comes the responsibility to continue to be considerate and protect others for all of our benefit.

Raghib Ali: Why it’s now time to unite behind the roadmap

24 Mar

Why it’s now time to unite behind the roadmapro 

Dr Raghib Ali is a Clinical Epidemiologist at the University of Cambridge and an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust.

When the Prime Minister unveiled the roadmap last month, I was relieved to see that he had not been swayed by those calling for a ‘Zero Covid’ strategy which was neither achievable nor desirable in the UK due to the huge costs it would entail.

The roadmap was broadly in line with what I had called for: a middle way between zero-covid and zero restrictions with a cautious, step-wise approach that was likely to minimise overall health harm and provided a clear path back to normality with no restrictions – and which could command wide scientific and public support. I was particularly pleased to see that priority given to children returning to schools and families being able to meet as the harms to education and health from these restrictions cannot be alleviated by government financial assistance.

I understand why some are frustrated by the slow pace of unlocking (particularly given the amazing success of the vaccine program) and as those who have followed my writings over the last year know, I am certainly no lockdown enthusiast.

The reason my views first attracted attention last Spring was because it was unusual for a frontline doctor to highlight the wider health harms of lockdown and to call for a comprehensive cost-benefit analysis to ensure that our response – and particularly school closures – was not causing more harm than benefit. And I argued against a second lockdown on the basis that it would only postpone and not prevent deaths; that compliance would be lower so reducing its effectiveness, and that it could cause more harm than benefit.

But I also accepted that Covid-19 had to be suppressed in order to prevent the NHS being overwhelmed and to reduce the health harms from fear. I also made clear that I would support interventions that could be shown to produce the least overall harm – including lockdowns – and accepted that they were justified when the NHS was not able to deliver all essential services, as happened in both waves.

The unexpected arrival of safe and effective vaccines transformed the situation as lockdowns were now able to actually prevent deaths, and so changed the cost-benefit analysis.

I also realised that earlier cost-benefit analyses for England had not distinguished between the health and economic harms caused by lockdown versus those of coronavirus itself, and updated analyses have now shown that the ‘health harm balance’ is likely to favour lockdown.

The current lockdown has also been more effective than I expected as compliance has remained high – perhaps because the second wave was so much worse than many expected. I know that many are sceptical about the risk of a third wave if restrictions are lifted at the end of April when cohorts 1-9 (all over 50s and those at increased risk) have been offered their first dose.

Although some of the models presented to us over the last year have rightly been criticised, the reasonable worse-case scenario projections presented to SAGE in July on the number of deaths and hospitalisations were remarkably accurate and much closer to the truth than other more optimistic predictions, including mine (I over-estimated how effective voluntary behaviour change would be in preventing a second wave and did not foresee the emergence of the new variant).

So although I do think their projections for the coming summer are overly pessimistic (as they didn’t fully account for seasonality and people’s behaviour change) they cannot be taken lightly.

My own simple calculations show that based on the data we have to date i.e. a 90 per cent take-up and 80 per cent effectiveness from one dose against hospital admissions (which is the key metric in relation to the NHS being overwhelmed) the projections for up to 5000 daily hospital admissions and 500,000 in total until the end of 2022 (roughly the same number we have had so far) are possible in the scenario where peoples contacts went back to pre-covid levels as about 30 per cent of groups 1-9 (about eight million people) would still be at risk.

Two key uncertainties remain – how effective the vaccine will be at reducing transmission with estimates ranging from 30 per cent to 90 per cent and how many contacts people will go back to having once restrictions are lifted.

It is of course unlikely that we would reach that level because as Covid increases, behaviour changes and new restrictions would come in – but this is exactly what we are trying to avoid. And if sufficient numbers of the unvaccinated are not ready to go out because of fear, the economy will not recover as quickly. (About 40 per cent of adults remain worried about catching the virus, despite 50 per cent being vaccinated.)

It is also now clearer (certainly with the new variant) that voluntary changes to behaviour were not sufficient to prevent second (and third waves) and what is happening in Europe with new lockdowns, schools closing and ICUs filling up again is a reminder how easily virus spreads in Spring too (as it did last year)

The experience of Israel is more encouraging, but we need to remember that they first reduced restrictions on February 7 when 80 per cent-of over 60s had received both doses – a milestone we will not reach until June – and that hospital and ICU admissions had only fallen by about 50 per cent one month later.

So while it is true that the rapid progress of vaccination means we are now in a better position than we expected a month ago, we still need to see the impact of each step before taking the next one. And given the remaining uncertainties, we need to get infections as low as possible and vaccinations as high as possible before the next step to minimise the risk of a third wave – with all the direct and indirect health harm that would cause.

I also accept that there need to be strict border controls and quarantines in place until all adults are offered vaccination to reduce the risk of new variants spreading but this cannot go on indefinitely. Vaccines can be adapted to deal with these new variants before the autumn in the same way we do every year with influenza (which actually mutates much more than SARS-CoV2).

We also need to urgently build NHS capacity (particularly in staff) to deal with the huge waiting lists and be prepared for the likely seasonal resurgences of Covid and flu to ensure that this is the last lockdown.

Finally, even for those unconvinced of the arguments above, given that the roadmap will definitely pass, I think it would help with compliance if the public see that Parliament is united behind the roadmap. If compliance falls too far, we could end up with the worst of both worlds: economic and health harms from restrictions and poor control of Covid, as has happened in other countries.

The divisions and polarisation of the last year were perhaps inevitable but I think it is now time to leave those arguments behind. After all, we are all trying to achieve the same thing – to minimise the overall harm to health, the economy, education and society as a result of COVID and the response to it.

I accept that this is not straightforward given the uncertainties that remain. But we have to make a judgment based on the evidence available and I have concluded that the roadmap does achieve that. It thus gives us the best chance of avoiding a third wave, a fourth lockdown and of getting our lives back to normal as quickly as possible.

Raghib Ali: Why we should put our children first and keep schools open

30 Dec

Dr Raghib Ali is a Clinical Epidemiologist at the University of Cambridge and an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust.

We are “back in the eye of the storm” – the grim warning from the head of the NHS as we passed the first peak of Covid-19 hospital admissions across England. Pressure in many hospitals across London, the East and the South East is now much higher than when I was on the frontline in April, as we try to keep all elective services going to avoid the pain, suffering and loss of life caused by these services being cancelled last time.

Which is why it is of course essential that both government and the public do what they can to reduce the harms of the virus.

However, the interventions implemented should be based on some key criteria – firstly, that there is good evidence for effectiveness in reducing Covid-19 infections in the over 60s, hospital admissions and deaths; secondly, that is has been shown to produce more overall benefit than harm: i.e. any proposed intervention must focus on the balance of benefits and harms, in order to produce the best overall outcome; thirdly, where harms are certain but benefits are uncertain, the intervention should not be used; and, fourthly, that there is no reasonable, alternative option which produces less overall harm.

And it is with these criteria in mind that the current decisions regarding school closures should be taken.

Looking back to the first wave, the decision to close schools was understandable, as so little was known about the risks to children, teachers, parents / household members and the role of schools in community transmission. However, we now have much more evidence about this and it is clear that schools are safe for children and the best place for them given the multiple harms to children from school closures which have been well-documented.

If this pandemic has a silver lining, it is that the risk to children of dying from the Coronavirus is almost zero, and much less than their risk of dying from accidents or even influenza (Although as I have stressed previously, the virus is overall deadlier than flu, especially in those aged over 65.) Although they may be equally likely to be infected, they are less likely to develop severe disease and while there are reports of ‘long Covid’ in children, it is not as common as in adults and certainly its overall harm is far less than that of not going to school.

It is also very good news that the risk to teachers is low, with studies from the ONS having shown that they were at lower risk of dying than the general population during the first wave, despite the likelihood of having been exposed to tens of thousands of infected children (and other staff) in the two weeks before schools closed.

This was not that surprising as most teachers are at very low absolute risk due to their age and being generally in good health but of course, all should have a risk assessment and those at high risk should be given additional protections.

And since schools fully re-opened in September, the ONS have also shown that teachers were at no higher risk of infection than other key workers.

And, now that the Oxford vaccine is approved and there is less scarcity, it makes sense to give priority to vaccinating teachers to reduce staff absence and help ensure schools stay open.

With regard to transmission and the risk to household members and the wider community, evidence has shown that children are not significant drivers of community transmission and that there was no increased risk of severe Covid-19 outcomes for adults living with children – including crucially in adults over the age of 65. SAGEs own comprehensive assessment of the impact of the virus on children; teachers; and the role of children and schools in transmission came to similar conclusions. And while they only had low-medium confidence in the role of children and schools in transmission, they had high confidence in the harms of school closures on children’s education and health and increased inequalities.

Of course, it is possible that the situation has now changed due to the new variant which is likely to be responsible for the increased cases, hospitalisations and deaths in the regions where it is now dominant. However, the key point is that we do not have evidence (in the public domain at least) that these increases are due to increased infections in school children.

This is what needs to be shown – i.e: what number and proportion of hospitalisations and deaths can be linked to school children?

The fact that closing schools may decrease R overall (i.e: across all age groups) does not demonstrate that it would decrease hospital admissions and deaths (as they are so concentrated in those aged above 60.)

Even if this were shown, the decision should still be based on the trade-off / cost-benefit. i.e: does the harm from Covid-19 outweigh the harm from school closures – to children, their parents, society, lives and livelihoods, etc.

And even if that were demonstrated, alternative options should be explored – i.e: advising no mixing of school-age children with anyone over 60 / at high risk for a few weeks until they are vaccinated. I know that will be difficult for many – including my recently-widowed mother who would not be able to see my children – but there are no good options here and we have to find and choose the least harmful solution.

I appreciate how difficult these cost-benefit analyses are having worked with the Legatum Institute on their impact assessment tool to assist such decision making, but they must nevertheless be attempted,

As a school governor, I am also very aware of the huge efforts teachers and staff have made over the last term to keep children in school and provide the best possible education – despite the many challenges – for which they often receive scant recognition. But I am disappointed that some unions (not teachers) are again calling for schools to be closed knowing how much damage this did – especially to those from disadvantaged backgrounds – further widening of educational inequalities. (And although they say it would be for two weeks, we know how difficult it is to re-open schools once closed and two weeks could easily turn into two months.)

A good education is the only route out of poverty for most children, as I know from personal experience. As a child on free school meals attending one of the worst-performing primary schools in England, my chances of going to Cambridge and becoming a doctor were almost zero, but my life chances were transformed by getting a scholarship to a good secondary school and supportive teachers. But I was one of the lucky ones and the vast majority of children don’t get a second chance.

Also, like many children today, I would not have had access to the computers – or even books – and other support effective home/online learning requires and the only way to ensure that every child is given the same opportunity they deserve is by them being at school with their teachers.

In conclusion, all children have the right to a good education and they have suffered enough this year already. Unless there is good evidence that closing schools will significantly decrease hospital admissions and deaths, and that it would produce less overall harm over the long term – and that there is no better alternative – the Government should hold its nerve and keep schools open. It is time to put children first.

Raghib Ali: Christmas is going to be tough, but there is finally light at the end of the Covid-19 tunnel

21 Dec

Dr Raghib Ali is a Clinical Epidemiologist at the University of Cambridge and an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust.

The last few weeks have been an emotional rollercoaster. The month began with the euphoria of the first Covid vaccine being approved but ends with the dashed hopes of millions now living in Tier 4 and the wider fear of what impact this new variant of Covid will have on all of us.

The arrival of a safe and effective vaccine – much earlier than any of us had dared hope for – was a huge relief to all of us on the frontline that not only could we protect ourselves but, more importantly, our patients and those at highest risk in care homes and in the community.

But it will take months to vaccinate them all, and the recent increase in infections and hospital admissions is a stark reminder that the virus is certainly not beaten and we still have a long winter to get through.

So we need to protect those at highest risk in the coming months – and especially during the coming Christmas relaxation when most of us will be able to meet family and friends – in many cases after having not seen them for months. Although thankfully most of us are at low risk ourselves, about one in five people are at higher risk, either because of age or other risk factors like obesity and diabetes; heart disease and lung disease, and we can all play our part in helping them to stay safe through our behavior, and by following the rules and the guidance.

Of course we all wanted to spend time with our parents and grandparents, or children and grandchildren, over the Christmas break and it’s a huge disappointment to all of us now in Tier 4 that this will not be possible. But I am pleased that, for the majority of the country, they will still have the opportunity to make their own choice based on their personal circumstances and their specific situation, taking into account not just the risks of Covid but also the risk of being alone at this time for their mental health and wellbeing.

Many families are deciding to postpone celebrations with elderly relatives until the Spring when they are vaccinated, while for others the chance to enjoy the company of their loved ones, even for few hours, will be a lifeline – and particularly those for whom this Christmas may be their last.

I know from my own experience over the last year just how difficult these decisions can be.

My father was at extremely high risk because of his age and his underlying lung condition and getting Covid would have basically been a death sentence for him. And I knew I was at higher risk of passing it on to him when I was working on the frontline. And so I took all the precautions I could: only visiting him when I had been off the wards for two weeks, generally meeting outdoors, and being careful to maintain my distance and wear a mask indoors.

And although he was understandably afraid of being infected, he was always very keen for me to visit and at least have the chance to meet and talk and go for a walk together. And I know his mental and physical health would have really suffered if he hadn’t been able to see his children and grandchildren regularly. We were also very lucky to be able to celebrate a socially-distanced Eid and his 80th birthday with him over the summer.

Tragically he died suddenly and unexpectedly at home in October – not from coronavirus but from an unrelated cause – and of course I regret that I was unable to give him a hug or even hold his hand for the last few months of his life. But that is what he wanted. And I am very grateful for the time that I was able to spend with him in the weeks before he died, especially when so many others this year have not been able to do so.

So while we rightly look forward to enjoying this short time with family and friends, we must be careful too, especially with our elderly relatives, both in the coming days so we reduce our risk of getting infected, and when we meet them, so we reduce the risk of passing it on unknowingly. We should also remember those who live alone and do our best to make sure that no-one we know from our families, friends, or neighbours is left all alone over Christmas – and beyond. Even if we can’t meet them physically, at least we can give them a call or send them a card or a letter so they know that they are not forgotten.

This brief relaxation of rules for the majority of the UK also gives us the opportunity to demonstrate that we are able to make sensible decisions ourselves and take personal responsibility for protecting the vulnerable through voluntary changes to our behavior.

This will not only reduce their risk of getting Covid now and help the NHS to keep treating all its other equally important patients, but also show that we are capable of living responsibly with the virus and so enable compulsory restrictions – with all their associated harms – to be lifted in the coming months.

For countless families across the UK, including mine, 2020 has been the darkest of years with millions having suffered pain and loss, both from Covid itself and its wider impact. But the vaccines really do provide the light at the end of tunnel. They will save thousands of lives, not just from coronavirus but from all other causes by reducing fear, pressure on the NHS, and the harms of restrictions as they are able to be lifted.

This new variant is understandably causing concern but there is no evidence that vaccines will be less effective and even the four million doses due to arrive this year will have a very significant impact in reducing deaths and hospital admissions by vaccinating all over-85s.

No doubt, the months ahead are going to be more difficult than we may have hoped, and we will need to continue making sacrifices for the common good. But for the first time since this pandemic began, we can be genuinely optimistic that our lives will be getting back to normal in the Spring. Let’s not fall at the last hurdle.

Raghib Ali: The three-tiered system was working and England didn’t need this lockdown

23 Nov


Over the last two weeks, data has emerged from a number of sources which indicate that infections peaked nationally in the week before lockdown – and in most regions – including areas in Tiers One, Two and Three.  (All findings below are for England and are shown in figure above.)

First, the ONS infection survey, the COVID Symptom Study and RCGP surveillance data all show cases rising throughout September and October, but then starting to fall at the beginning of November (possible with a slight uptick in the days between lockdown being announced and starting, as people made final visits to friends, relatives, pubs, restaurants, etc.)

Second, estimates of R from SAGE, the MRC Cambridge Biostatistics Unit and the COMIX study also match this infection data, with R rising through September but then starting to falling and reaching one at the end of October (again, with a slight uptick between lockdown announcement and starting.)

Third, hospital admissions up to November 18th have stabilised, with the seven-day average beginning to fall for the first time, and a peak possibly reached on November 11th. This cannot be due to lockdown, since this would take at least two weeks to have an effect on  admissions, and so reflects changes in infections pre-lockdown.

And finally, deaths have also now stabilised, with the seven-day average being steady since November 11th  and, again, this can only be due to decreases in infection pre-lockdown, since it would take at least three weeks for the lockdown to impact deaths.

(As I have pointed out before, this also matches the experience from the first wave, where infections started to fall in the week before lockdown, given when hospital admissions and deaths peaked, but at that time we didn’t have the infection data to demonstrate that.)

Also, as hospital admissions have started to fall, the total number of Covid-19 positive patients in hospital has also started to stabilise for the first time. This has meant that NHS acute and general bed and ICU bed capacity has not gone above normal levels for the time of year in England or in any NHS region – although some Trusts have, sadly, had to cancel elective operations.

This data all indicates that that the regional tier system was working effectively enough in controlling community spread, particularly in the over 60s, and in keeping hospitalisations below a level that the NHS could cope with.

But of course, this data was not available at the time the decision was made that a second lockdown was needed. Indeed, the data on hospital admissions at that time was genuinely alarming, and it was essential to ensure that the NHS could continue delivering all services given the huge backlog of cancer screenings, tests, procedures and operations which had arisen and is still causing so much suffering.

We had to learn the lessons from the first wave and keep all NHS services running this time so we can save and improve lives from all causes – not just Covid-19. And given the NHS has limited capacity both in beds – and particularly staff – the only way that can be done is by keeping Covid-19 admissions below a certain level – which I think we can now say is roughly at the level where we are at now nationally, but of course there are regional variations.

So what explains these findings?

Although immunity from Covid-19 infections in the first wave could explain part of this, especially in London, where antibody levels indicate their rates of infection were more than twice as high as any other region, it doesn’t explain why infection rates have also started to fall in regions with very low levels of infection from the first wave (e.g. East Midlands, South West)

The findings are however consistent with changes in behaviour reducing Covid-19 transmission, which has now been demonstrated in three separate studies – the Covid-19 Social Study, the ONS Opinions and Lifestyle Survey and the COMIX study

All showed increasing compliance with measures (e.g. social distancing, wearing masks, washing hands, self-isolation and reducing social contacts) over the weeks preceding lockdown – and in all three tiers. This has been shown most clearly in the large Covid-19 Social Study, which has been longitudinally tracking compliance in over 70,000 people nationally asking respondents anonymously to self-report the extent to which they are following recommendations such as social distancing and staying at home.

Compliance improved over the last two months as Covid-19 infections were increasing– both nationally (as shown in the figure below) but also regionally – including in areas in Tier One (and even before the Tier restrictions came in.)

Further evidence for this also comes from the Google mobility data (also shown in the figure below) where reductions in journeys are seen from mid-September as COVID infections rise and again before mandatory restrictions came in. (A trend only disrupted by the late-October spike likely caused by the leak of the second lockdown.)

This improvement in compliance shows that voluntary behaviour change is an important factor – as would be expected in that people naturally change their behaviour as they perceive that their risk of infection is increasing.

We also need to focus on improving voluntary compliance with existing restrictions which have been shown to most effective – and least harmful – before adding in new ones. Simple, consistent public health messaging is critical, and seeking persuade people without resorting to fear – which also causes significant health harm, as we saw in the first lockdown, when thousands died and suffered because of fear – either of catching COVID or of putting a burden on the NHS. We need to try different messages and different messengers, including greater use of hospital doctors and GPs, who are most likely to be trusted.

As I have continually stressed in previous articlessustainable compliance is critical to any successful strategy to manage Covid-19– especially with social distancing and self-isolation. Restrictions are only effective if people are willing (and able) to comply with them – which is also why greater support for those required to self-isolate is essential.

We now have the first evidence from England that people can change their behavior enough to control community spread, particularly in the over 60s, and so to keep hospitalisations below a level that the NHS can cope with. However, this work very regionally and so it makes sense for any measures which are required (if voluntary compliance is not sufficient) to be targeted – but not to have blanket restrictions across the whole country.

It is also worth noting that it was possible to get R below one and infections falling while schools were open, and both the Government and Opposition should be congratulated for holding their ground on this.

In conclusion, the Government is right to be ending the lockdown on December 2nd and returning to a targeted regional strategy. While we await the details, I hope the evidence that has now emerged will persuade them to adopt a more voluntary approach which will significantly reduce the harms of restrictions – to health, education, society and the economy.

Although there is now genuinely light at the end of the tunnel with the impending arrival of safe and effective vaccines, we do have to continue to live with the virus for now and maximising voluntary compliance will help to ensure that we get through the Winter while minimising overall harm.

Raghib Ali: The Government needs a Plan B for Covid-19, lives and livelihoods. Here’s how one would work.

22 Oct

Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.

Last month, I described on this site what I expected the likely trajectory of the second wave to be; explained why a certain level of suppression was needed to enable the NHS to keep running all services running to prevent non-COVID health harms; and why that should not be achieved through more lockdowns, since the Government’s own cost benefit analysis showed it caused greater overall long-term health harm.

Since then, there have been increasingly pubic divisions between both scientists and politicians as to the best way forward over the coming months with opposing declarations and memorandums.  Some say current restrictions go too far, others not far enough – with the Government left in an almost impossible position of choosing the least worst option.

Today, I will briefly review the main strategies that have been proposed – herd immunity/focused protection (Great Barrington Declaration, GBD); further suppression/test & trace (John Snow Memorandum, JSM); the current tier system with targeted restrictions; and a potential alternative way forward.

In my last article, I outlined three criteria that any strategy / intervention should be judged by:

i) the evidence for effectiveness,

ii) whether a mandatory approach produces better outcomes than a voluntary one, and

iii) most importantly, that they produce less overall harm.

And today, I add a fourth – compliance – because all measures are only effective if a high enough proportion of people comply with them.

The Great Barrington Declaration

Having consistently highlighted the health harms of lockdown since May, I did of course welcome the GBD’s emphasis on the many harms of lockdown – particularly in developing countries without welfare states – where lockdowns are even more likely to cause overall health harm.

However, a declaration is not a policy and there are still too many unanswered / unanswerable questions which have been highlighted by many others.

Although I fully agree on the need to focus protection on care homes & hospitals, I am not yet convinced that it is feasible to shield the very large numbers of vulnerable people in the community while Covid-19 transmission is high (especially for those who live in multigenerational households).

Also, the number of ‘non-vulnerable’ who would be symptomatic and hospitalised in the coming three to six months (about 50 per cent of COVID admissions are currently aged 18- 64) would make it very difficult to maintain all NHS services – there is simply not enough spare capacity (particularly of staff.) And no country has successfully followed a herd immunity strategy.

It also does not currently have public support (more than 2:1 oppose it) which would be essential in maintaining compliance with shielding for the vulnerable; and in persuading the less-vulnerable to be exposed by returning to normal life.

Finally, its advocates have not shown that it will cause less overall harm which is, of course, the key overall metric it should be judged by.

The John Snow memorandum

In response to the GBD, the JSM was released. I understand the rationale of those who advocate a second (so-called ‘circuit-breaker’) national lockdown who believe that is better to have a shorter lockdown now than a longer one later – which may well be true – but this is not the key question, which should be: is it less harmful than not having one at all?

The limitations and harms of lockdowns have been well documented and I will only add a few points.

There is insufficient evidence that a two week lockdown will achieve its aims (Israel’s second lockdown has already lasted four weeks) and it may not be possible to lift it after two weeks if cases are still rising. And this strategy may just lead to a cycle of lockdowns which is not sustainable.

Lockdowns are only effective if they are complied with (Israel had much lowers levels of compliance in their second lockdown) and, even with current restrictions in the UK, compliance is lower than it was during lockdown and there is no guarantee it will be high enough to be effective.

The models only show that a lockdown may reduce Covid-19 deaths, but these have not modelled the number of non-Covid lives that will be lost or adverse health effects from other causes.

Although the intention of the circuit breaker is to buy time to get Test &Trace (T&T) back on track and ensure the NHS is prepared, it is hard to see how two weeks would make much difference when the NHS has had months to prepare.

T&T is of course an essential part of the solution but, again, there is insufficient evidence that we will ever be able to control the virus through T&T – we tried this over the summer when virus levels were almost zero after one of the longest lockdowns in Europe and it hasn’t worked here – or in the majority of countries in Europe.

It is also not true to say that ‘the only thing that works is lockdowns’ – social distancing and sel -isolation before lockdown here was bringing R down, and Sweden has showed it is possible to overcome a first wave without one – which I will return to later.

Finally, although public support for a two week lockdown is currently high, this would change if it was made clear that it could be 4 or 6 weeks or that it may well cause more long term health harm than benefit.

I know and respect many of the scientists supporting both positions and know they genuinely believe their strategy will cause the least overall harm, but I have not signed either the GBD or JSM. Neither adequately acknowledges the limitations and harms of their approaches or the uncertainties of the evidence – and both are overly confident in their assessment of their effectiveness.

The Government’s three-tier system

I still think the current gGvernment strategy of suppression to keep cases low enough to maintain all NHS services and minimise non-Covid health harms while trying to protect education and jobs is a reasonable compromise. Furthermore, if virus levels get too high, fear increases and people don’t come to hospital, don’t go out and the economy suffers, etc.

I certainly support the targeting restrictions based on the local level of cases as opposed to blanket national ones. I find it hard to understand how it can be possibly be fairer to destroy jobs and businesses all over the country including in areas where hospitalisations are extremely low than to target restrictions on those areas where they are highest and the NHS is under pressure. This should not be a political issue, or North vs. South – it’s just common sense.

We can only get through this crisis by supporting each other, and by keeping the economy open in as many places as possible, we can help fund businesses and jobs in those areas that are forced to temporarily close until the pressure on the NHS subsides.

There is also evidence that the current measures are working – R is stabilising (or even falling) in most regions at about half the level of the first wave, and the NHS is not being overwhelmed. However, they have not yet bought R down below one, and hospitalisations and deaths are still  rising.

The key problem appears to be compliance, and we need to focus more on how we can improve compliance with existing restrictions rather than increasing restrictions. After all, the purpose of restrictions (& lockdowns) is purely to enforce social distancing. We urgently need to analyse levels of compliance by local area and to understand what is driving lack of compliance.

For example, despite good intentions, only 20 per cent of those required to self-isolate are doing so, and it may be that financial incentives may be more effective in sustaining compliance with testing and self-isolation (e.g. paying people to self-isolate, as in Germany and Sweden).

Some people also think the measures aren’t working and so say, ‘What’s the point?”, but this is not true, which needs to be stressed.

So think it is reasonable for the Government to maintain its current strategy for three more weeks to see the effectiveness of the Tier Two and Three restrictions and devolved nations ‘circuit-breakers’.

A potential Plan B

However, we also need a Plan B to get us to Spring – and potentially longer if vaccines / treatments / mass testing are not as effective as hoped.

I would therefore ask the Government to consider an alternative strategy which may cause less overall harm based on the Swedish approach, but with much better protection of the vulnerable, especially in care homes. This is now much more achievable than in the first wave – because cases are lower, testing and PPE are more available. Individual risk calculators will now also  enable, smarter, voluntary shielding of the community vulnerable.

The key point is that Sweden has shown that it is possible to suppress the virus and get over their first wave (and so far control their second wave) without a national lockdown; without reaching herd immunity and without an effective T&T system. And while keeping schools and businesses open – and so reducing overall harms.

The Swedish approach has been widely misunderstood – the official government strategy is ‘to limit the spread of infection in the country and by doing so, to relieve pressure on the health care system and protect people’s lives, health and jobs.’

And as its Chief Epidemiologist, Dr Anders Tegnell, has said, Sweden is not trying to reach herd immunity (and has not achieved it) and it did not encourage the non-vulnerable to return to normal life. Indeed, its government is strongly encouraged social distancing, reducing social contacts, plus th use of public transport and working from home).

It has also introduce many other measures (i.e: closing universities, table-service only in restaurants, limited gatherings to 50 people.Tegnell has described the policy as a ‘voluntary lockdown’ – and generally the levels of compliance have been very high.

The Government has stressed personal responsibility and trusting the public with simple, consistent, public health messaging and tried to build public consensus and trust.

Of course, there are differences between Sweden and the UK, and there is no guarantee that its approach would work here, but the principles are still valid. The Sweden model is also not a cost-free option – and may lead to more Covid-19 deaths in the short term than would otherwise have been the case – but that is not the key metric, which is whether the strategy will lead to the least overall health harm in the long term.

The key to any successful strategy is sustainable compliance – and it must therefore have public trust and confidence. Open debate is important but, as I wrote in June, ongoing divisions lead to both fear and complacency, undermine public confidence and compliance – and can cost lives and livelihoods.

We therefore need doctors, scientists, and politicians to get behind the same overall strategy and I think this will only be possible if we can show which one causes the least overall harm.

The Government should therefore immediately bring together doctors, scientists and economists to conduct a comprehensive cost-benefit analysis of these four options (similar to the one they have already conducted) and come to a consensus – which should then be shared with the public and other scientists.

I have made my own assessment, but I neither have access to all the data nor a monopoly on wisdom and so am happy to accept whichever option comes out best – and hope others will do the same.

I end with the same conclusion as in June: ‘Finally, of course we are not primarily ‘pro- or anti- lockdowners’ – we are all ‘pro-protecting lives and livelihoods’ and wanting to recover from this crisis as quickly as possible. And so, we must put aside our differences, compromise and come together in the national interest. ‘A house divided against itself cannot stand.’