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. He writes in a personal capacity.
Last week, I explained on this site why there is still significant potential for harm from a second wave – both directly from Covid-19, and indirectly from its effect on the NHS’ ability to keep all essential services running.
Today, I will try to address the key question as to what our response should be. The situation now is almost the exact inverse of the one I discussed in June in relation to lifting lockdown restrictions. The divisions remain, and the public health messaging still needs to improve but there is now wider acknowledgement of the need to balance the harms of Covid-19 with those of lockdown.
I wish I had the same confidence as the armchair epidemiologists about the best course of action, but the truth is that although we do now have actual experience of dealing with first waves (as opposed to just modelling), ‘the science’ is still highly uncertain, with conflicting evidence for the effectiveness of different strategies (mitigation vs. suppression) in different countries.
I have set out in more detail on my blog why it is difficult to draw definitive conclusions but, in brief, the evidence we have is generally from low quality observational data which have significant limitations – and so we don’t know for certain if the reduction in disease was due to the intervention or other factors.
Also, many interventions were instituted simultaneously and so we don’t know which had the biggest effect in reducing infection. However, it is clear that the measures taken pre-lockdown (self-isolation and social distancing) did reduce infections and must remain the cornerstone of our response.
Between-country comparisons are particularly problematic as countries differ in so many important ways but I will briefly discuss the experience of Sweden as its approach has attracted so much attention (and supporters and detractors). Compared to its nearest neighbours, it has (so far) had a five to ten times higher death rate with a similar economic decline. This supports the case that those countries that locked down earlier had less deaths from Coronavirus (because they had less cases) – as would be expected given the virus needs human interaction to spread.
However, when compared to the UK, Belgium or France, Sweden has a similar level of deaths with a much better economic performance and has demonstrated that first waves can be ended with measures short of a full lockdown (including, crucially, keeping schools open).
But it is too early to say that Sweden has escaped a second wave as they generally occur about three months after the end of the first and Sweden’s only ended in July. However, I think it is unlikely as they have not reached the 20 per cent antibody level which may provide herd immunity (they are at about seven per cent.)
Also, in general, lockdowns postpone rather than prevent infection (although the death rate should be lower in second waves, due to better treatments) and Israel provides an example of their limitations where they now have a much larger second wave of deaths which has led to a second lockdown. And this cycle of lockdowns would need to be repeated until vaccines / very effective treatments become available – of which there is no guarantee.
Of the large European countries, Germany has (so far) managed the Coronavirus most effectively, with lower deaths in the first wave (and less economic damage) and no second wave yet – which seems to be due to better testing and tracing, and shielding of those at highest risk.
However, it is still too early to say which countries’ strategies are correct, and we won’t know until the end of the pandemic. But, of course, we have to make decisions now based on the best evidence we have.
Although I don’t agree with all the measures, I think the approach outlined by the Prime Minister and Chief Medical Officer – which can be seen as a hybrid mitigation / suppression strategy – is broadly correct ,and rightly focuses on the balance of benefits and harms in order to produce the best overall outcome.
And although there is now broad agreement that we must try to prevent a second national lockdown, there is already pressure to increase the restrictions further.
But before doing this, I would urge the Government and Parliament to ask these three questions:
- First, how good is the evidence that the intervention works in reducing Covid-19?
We have a much better evidence base now, with the different interventions used over the summer and some data from the ‘natural experiments’ being conducted as devolved nations introduced slightly different measures (e.g. on the rule of 6, size of bubbles, household mixing, etc.)
Measures should also be in place for at least two weeks to assess effectiveness before considering new ones; but should also be reviewed regularly, and not kept any longer than necessary. (The Government should also urgently fund trials to test different interventions in different regions to get better evidence.)
- Second, is it clear that making these restrictions mandatory (with penalties) makes a significant difference to compliance/ effectiveness of these measures?
In some cases, this is clear (e.g: breaking self-isolation rules where the voluntary system was not working well) but, in general, the harms of (particularly social) restrictions could be reduced by making them voluntary.
- Third, and most importantly, does it clearly have more benefit than harm in relation to overall health, quality of life, education and jobs?
It is hard to see how a second national lockdown could be justified, even on health grounds, with the Government’s own health cost-benefit analysis showing that, in the long-term, the health impacts of the two month lockdown and lockdown-induced recession are greater than those of the direct Covid-19 deaths. (Importantly, this analysis was on the basis that mitigations to reduce Coronavirus infections (e.g. social distancing) were in place – otherwise the harm from Covid-19 deaths was more than three times greater than lockdown.)
Other analyses have also come to the same conclusion – particularly when also considering the economic costs of lockdown – which also harms health and society.
The evidence for the effectiveness of local lockdowns is mixed, but they will still have associated harms – and will exacerbate inequalities and so similar comprehensive, cost-benefit analyses are needed – with the input of economists and educationalists as well.
New lockdowns should only be considered when there is clear evidence of more benefit than harm, and closing schools must be the last resort.
We need to prioritise those interventions that most reduce the direct and indirect harms from Covid-19 (which will therefore decrease the need for more restrictions) while doing the least harm to everything else – particularly other health harms, education, and the economy.
Based on our experience, these are three interventions which could save thousands of lives this time:
- First, improving the public health messaging and reducing fear. Thousands died and suffered at home either because they thought they needed to ‘stay at home’ to ‘protect the NHS’ even when they were seriously ill – or they were too scared to come to hospital. We need to reassure the sick and ideally provide separate Covid-19 units/ hospitals to give them more confidence to attend – which also means keeping Covid-19 hospitalisations at a low enough level to enable this.
- Second, ensuring that all NHS services are kept running. while also managing Covid-19. Millions have suffered, and thousands will die, through the closure of NHS services – which we now know was not necessary and mustn’t happen again. We must urgently establish the level at which Covid-19 admissions will overwhelm the NHS – not in the sense that we used before (i.e. emergency and critical care) – which is no longer a risk – but all other essential services as well. And this time, we must use the increased capacity available from the Nightingales and private hospitals.
- Third, protecting those at highest risk including care home residents and hospital patients with regular testing & isolation, and ‘smarter shielding.’ This can be much better targeted now with all the data we have and individual ‘Covid-19 risk calculators’ should be urgently rolled-out to help people understand their own risk and make their own informed decisions. It will also help people to overcome their fears and seek medical help when required, as well as help to reduce Covid-19 disparities.
I do not, however, believe this shielding should replace the other measures to suppress the virus in the general population. There is currently not enough evidence to show that it is possible to effectively shield all those at high risk or to reach herd immunity without significant direct harm to the lower risk groups where adverse health effects occur in about a third of cases, including the young and those with mild symptoms.
(Of course, test and trace is also critical – and there is certainly room for improvement, particularly in schools, but the UK does have one of the highest testing rates in Europe.)
The public have the most important role of all in controlling the virus, and so must be convinced to follow the current restrictions and given support, as needed, to do so. To improve public consent and compliance, the Government should publish and explain the evidence – and be honest about the decision-making process, the uncertainties and the trade-offs.
The coming months will be challenging for all of us, and we will need to learn to live with the virus and change our behaviour accordingly. For some, that will mean reducing our social contacts; for others – overcoming our fears; and for all, looking out for the vulnerable, being patient and making sacrifices for the common good.
Finally, having served on the front-line, I am only too aware of the death and suffering that Covid-19 causes – but the harms of a second lockdown would be greater. And so we must follow the current measures and by protecting society, education and the economy – as well as the NHS – we will save, and improve, the most lives.