By Professor Brian Morgan and Professor Anthony Campbell
In the two months prior to the first lockdown in March, the UK was groping its way through a fog of uncertainty. Lots of mistakes were made. But the first lockdown was probably justified because we knew so little about the virus and the priority then was to save lives, save the NHS etc.
But now, in November 2020, 8 months after the first lockdown, we know more about COVID-19. There is still uncertainty, but it can’t be right that we are now planning to do almost the same thing in Wales as we did back in March. e.g. we know who is most likely to be impacted by the virus, where the hotspots are, how they arise and how to treat the virus to reduce the chance of death.
However, in recent months many scientists have also raised the important point that the ‘cure’ (i.e. the lockdown) introduced in March may be more damaging than the virus. Evidence is accumulating on the adverse impact of the lockdown on non-COVID health problems, [cancer rates] on the education of our children [m] and, of course, on the economy.
The Economic Impact
Lockdowns cause recessions (in Q2 UK GDP fell by 20%) and have an adverse impact on people’s wellbeing through lower incomes, increased unemployment, decreased job opportunities and increased uncertainty about future wealth.
Against this backdrop, the WG introduced a ‘time-limited’ lockdown or ‘firebreak’. It stated that it is following the scientific evidence – in this case that of its Technology Advisory Cell (TAC). But TAC’s report presents fairly ambiguous evidence – suggesting that they were not completely convinced of the efficacy of a full lockdown:
“Both intervening and not intervening will cause harm: long and short-term harms, direct and indirect harms, economic harms, social and health harms. Limiting the size of the recession will save lives in the future as mortality is closely related to income and life chances. Economic harms are also non-linear as normally viable businesses will go bust with a huge loss of human and physical capital.” (TAC)
Their main argument for the lockdown is to reduce the ‘R’-rate – bringing it down from around 1.3 to a figure below 1:
In summary, the greatest impact on reducing the R-rate would come from closing schools, particularly secondary schools (this could reduce the R-rate by up to 0.5), controlling activities in higher and further education (e.g. more online teaching could reduce R by 0.3) and continued working from home (this could also reduce R by around 0.3).
However, other actions, like the closure of non-essential retail and preventing different households from meeting might only reduce R by 0.2 – as long as social distancing is in place and people wear masks. So the TAC report indicates that the scientific evidence in favour of a full lockdown is ambiguous: the closure of non-essential retail will have only a marginal impact on the R-rate.
Apart from ambiguity over the R-rate, another major problem with the current lockdown strategy is its ‘stop-go’ nature. For example, we have already been told to expect another lockdown in February and therefore this ‘stop-go’ policy will need to be in place until a vaccine is found – i.e. for another year or possibly longer.
However, if an effective vaccine is not found then Government advisors have said that we are going to have to learn to live with the virus. That’s Fine! But what does this say about a series of ‘stop-go’ lockdowns? Surely we can’t keep shutting down the whole economy every few months for the next couple of years? This strategy can’t be open-ended?
Key questions about the ‘firebreak’
Is there a ‘middle way’ between lockdown and herd immunity that would reduce the spread of the virus and open up the economy? Would it induce greater compliance from the general public?
These are some of the difficult political questions that now need to be faced and there is also the issue of competence. Does the government have a coherent long term strategy? How effectively is it introducing new rules and implementing a robust test and trace scheme?
The business sector in particular is complaining about a lack of information and last minute changes to the policy. There is limited information about what can and can’t be done during lockdown and particularly what happens after lockdown. e.g. in hospitality – what do hotels do with current guests or current bookings? What can brewers and others do about unsaleable stock? And what does ‘non-essential’ mean? etc.
Clear, concise guidance is needed but not readily available. As ever, it is far easier to impose a general lockdown than to introduce it in a way that allows businesses to adjust in a timely and effective manner. [And need guidance for the restart]
A more nuanced approach
We need to find a ‘middle way’ that avoids us relying on continuous ‘stop-go’ lockdowns. A more targeted approach could enable us to open up more sectors of the economy and improve the wellbeing of people living with the uncertainty of current and future lockdowns.
This middle way could involve shutting down only those areas where the R-rate is high and the virus is spreading rapidly. This would need to be linked to travel restrictions being introduced between these areas and the rest of Wales. Some combination of local lockdowns and travel restrictions could offer better outcomes to the questions posed above compared with the current firebreak.
But to safely introduce this ‘middle way’ will require a well-designed, effective and locally delivered testing system to be put in place, accompanied by a robust tracing scheme. The aim of this local scheme would be to quickly diagnose people (with symptoms?) and trace their contacts in order to assess both the level of infection and the spread of the virus within the local community.
Test and Trace
In developing a robust test and trace scheme, Wales does not have much to learn from England. There the testing system has been outsourced and badly managed. It has led to poor quality control, a lack of coordination across the NHS and poor alignment with the primary-care system.
A better approach has been developed in Wales where the test and trace system is run in collaboration with Public Health Wales, Welsh Government and local authorities. The results in terms of outcomes is better – ten percentage points better than in England. But this is still not good enough. Other countries (Germany, S Korea) have far more effective systems in place.
Perhaps the Welsh system could be improved by encouraging (and incentivising) greater involvement of local GPs in the track and trace scheme allied to greater use of private sector and university testing facilities. Local businesses could test their employees. After all, every GP surgery and medium sized businesses could be equipped with the kit needed to offer testing services for local people. District nurses could be used to collect samples from the local community and more use made of volunteers to support the tracing efforts. Those asked to isolate should be given support – including income support. Private sector couriers could ferry the tests to NHS labs which could ensure that the proper procedures are followed to deliver a national test and trace scheme.
To be successful the scheme would require:
- A bottom-up approach – using local primary care providers and businesses,
- A close working relationship with other sectors – including volunteers, local authorities and the private sector – to deliver the tracing scheme, and
- A local delivery system to support the test, trace and isolate strategy – supported by central coordination and
- Increased resources from Public Health Wales to incentivise collaboration and delivery
Funding the scheme
The financial resources required to underpin the system would be relatively small.
For example, the WG is making £300m available from their ‘resilience fund’ to support businesses during the current firebreak and, according to TAC, this is forecast to save 750 deaths by end of March 21. [The WG has also asked for the Job Support Scheme (HMT) to be brought forward for a week to support the Welsh lockdown. “Jobs will be lost without Treasury support”.] This level of financial support equates to around £500K per life saved. Economists and others have argued for years – what is the price of a life? Well in the NHS it’s around £50K. So the current firebreak will cost much more on average per life saved.
However, a much smaller sum could be spent supporting local tracing efforts, improving access to private sector testing sites and surgeries, providing financial support to those going into self-isolation, and integrating Public Health Wales with local primary care providers to speed up testing and tracing. Together, these actions could help improve the test and trace system and allow the opening up of the economy. This could help us avoid the disaster of heading into yet another firebreak in three months’ time. It could also improve public confidence and even induce greater compliance.
Once a robust local testing system is in place, communities should be updated frequently on the R-rate in their own local area. Having this information on a regular basis will make them more likely to comply with social distancing rules. They might even develop greater trust in directives from government. The overarching aim should be to increase our capabilities to tackle the virus, improve public confidence and encourage community compliance. This would help save the economy from the adverse effects of intermittent recessions for the foreseeable future. It would safeguard jobs and improve wellbeing.
To conclude, when we exit the current firebreak we need to ensure that an effective, localised test, trace and isolate system is in place, allied to travel restrictions. Social distancing rules will need to be more effectively communicated and enforced. Then, if the virus begins to surge, a targeted series of local lockdowns could be more effective because we would have more local data on the outbreak. This targeted approach would be better for the Welsh economy than a continuing series of ‘stop-go’ lockdowns and it could also lead to better control of the virus by encouraging compliance.
ANNEX on COVID 19
General Notes on What We (Think We) Know about COVID-19
- There have now been some 35 million cases of COVID-19 detected world-wide, with more than 1 million deaths. The death rate for under 40s is tiny, less than 1 in 10,000 of those infected. For those aged between 40 and 60 it is closer to 1 in 1000. But for those over 60 the death rate of those infected is 1 in 58 (1.7%). For children the threat is vanishingly small.
- Lockdowns have been disruptive, substantially affecting mental and physical health, and harming the economy. However, the data is poor that complete lockdowns, as opposed to careful management of how the virus is transmitted, really reduce the number of deaths from COVID or reduce pressure on the NHS. Also the evidence on the effect of lockdowns on reducing the R number and the spread of the virus is weak.
- The evidence suggests that it doesn’t matter if young people get COVID so long as they don’t transmit it to old people. But it is a big step from accepting this statement to fully supporting the adoption of the so-called herd immunity approach. This suggests allowing a large uncontrolled outbreak in the low-risk population while protecting the vulnerable. Proponents suggest this would lead to the development of infection-acquired population immunity in the low-risk population, which will eventually protect the vulnerable.
- Herd immunity forms the basis of the so-called ‘Great Barrington Declaration’: “The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection.” However, expert virologists argue this approach is flawed and the Declaration does not offer any practical method for effectively protecting the vulnerable.
- The problem is that some people are still not obeying basic social distancing advice such as: keeping 2 metres apart where possible, wearing masks in public, regularly washing hands with soap or ethanol and not meeting groups of people indoors in poorly ventilated spaces.
- Also, we still do not know for sure about infection rates. Controlling community spread of COVID-19 is the only effective way of protecting society, (through social distancing etc.) until safe and effective vaccines and therapeutics are available. And information is urgently needed on the safety and efficacy of potential vaccines.
- Rapid testing, tracing and isolating are vital to the eventual suppression of the virus. This strategy has been poorly applied the UK as a whole and the roll out in Wales has not fared much better. Yet this approach has been a huge success in countries such as New Zealand and Japan. Also Germany seems to have developed a better approach than the UK.
- The good news is that SARS-CoV-2 doesn’t appear to mutate anything like as rapidly as influenza virus. This means that immunity should last for some time.
- Finally, one simple piece of advice: It is a good idea to take vitamin D daily if you are in the high-risk group.
a) There are several technologies. The nearest to availability is probably the Gilbert Oxford vaccine, based on a genetically engineered adenovirus, and one from Imperial College based on liposomes containing messenger RNA coding for the spike protein and some other key virus proteins. These would both be administered intra-muscularly. This will generate IgG antibodies and possible T-cells that would kill other cells infected with SARS-CoV-2. But naturally, the first defence against a respiratory virus is the production of IgA antibodies which are the only type that can be secreted onto the respiratory track. So, people need to be given the vaccine both intra-muscularly and nasally.
b) However, although the two vaccines most likely to become available may prevent death they are unlikely to also prevent infection, and thus won’t prevent carriers being generated. In addition, the amount of viral particle given is huge, and could possibly cause a bad reaction in some people.