Needed — a Strategy
On Friday night a panellist on Any Questions suggested the government was trying to respond to the CoViD crisis in a piecemeal fashion when what was really needed is a strategy. By a strategy she meant a consistent plan to manage the number of cases down until the virus died out in the UK population and to ensure it is not re-imported.
It had not occurred to me before that such an outcome could be a viable aim, but once the idea is raised it becomes seductively attractive. What if that could actually be done? What would be involved?
First of all, it would be necessary to take steps to reduced the average ongoing infection rate below one so the virus went into a decline. The lower the rate, the faster the decline. Secondly, we would need tight border controls to prevent a decline here being replenished by fresh supplies from overseas. In fact, if every country adopted such a strategy, we could see the virus off, perhaps in a matter of months.
So how could a strategy to lower the number below one achieve that? Well, we know a full lockdown did that, but we also know there are huge problems sustaining such a lockdown over a long period. Businesses need to be able to operate reasonably normally or they cease to exist. People’s prospects and careers would be ruined. Unable to see friends, people’s mental health deteriorates. Life, which is already hard for many, becomes too hard for some. Basic human needs go unmet. There comes a point when more people have lost more time out of their lives and have suffered more collective misery, than would have been lost by those who die prematurely as a result of the outbreak. Where that point would be I don’t know, but I do know that I have lost a Summer I can never get back. I will not live longer to compensate. I am more likely to die earlier because of the impact on my health and well-being from the additional stress of living under the restrictions. How many years can we take from healthy lives to protect the final years of the dying? Where is the balance of the maximum good for the maximum number here?
The government’s response to that problem is to try easing the lockdown until cases rise higher than they like and then re-impose it in a piecemeal fashion wherever the number goes higher than they’re prepared to accept. However, all that does is ensure the problem will remain with us indefinitely and life will not return quite to normal for a very long time. There is no plan to manage the problem out of existence; to allow us to hope life can be normal again and personal freedom restored. We cannot hug friends. We cannot even see many of them. We have lost our social networks on which many of us depend for support and value. Some ignore the rules because they are too hard to bear, and gain the approbium of the rest of us.
There are different approaches which have been tried around the world, and these are all worth considering. China used a lockdown very effectively, and that is, perhaps, what has made the lockdown model so attractive to governments around the world, but China is a particular case. First of all, it is not a democracy, but a dictatorship. It has the resources and will to clamp down on its population very hard indeed when the government deems it necessary. It was also dealing with the initial outbreak of the infection, which gave it different objectives to achieve. Faced with a growing outbreak in one city in one province which was spreading across the face of the country and beginning to escape to the rest of the world, it made sense to a totalitarian government to try to nip the problem in the bud by quarantining the source city and province as tightly as it could. As a result, China managed to contain the virus fairly effectively in a couple of months, although not quickly enough to prevent it escaping its borders. However, that was achieved with military roadblocks and absolute control on movement. People in the affected areas could not leave and were heavily policed within them. A totalitarian state with strong physical and secret police forces and a large army can do such things. More libertarian societies will find that harder to achieve, lacking those basic resources and the will to use them.
South Korea, one of the countries next affected, already had effective centralised disease monitoring systems which meant contacts of cases could be rapidly identified, tested, and isolated. This kept the virus down fairly effectively and allowed the country to get and stay on top of the problem. There was one super-spreading incident involving a leader of a religious cult who came back from China and refused to isolate as recommended. Perhaps it was this success that led some countries to pursue a test, track, and trace idea, but with less success because they relied on untested technology.
Sweden took a very different approach, carrying on almost as normal. With a poulation of around 10 million they have had nearly 90,000 cases, whereas the UK has had nearly 400,000 with six times the population. They have therefore had 9 cases per thousand of population against our 6.3. They have had 0.6 deaths per thousand against our 0.7, so the higher case rate has not translated into more deaths. However, Sweden has a much lower population density than the UK, at 24 people per km2 against our 279. For comparison, approximately 1.2% (12 per thousand) of a population die every year in the normal course of events, so the extra 0.6 is not that large a difference.
New Zealand locked down hard and fast when the virus first appeared, and closed its borders. As a result, they have had few cases.
What emerges from this is that a lockdown can work, but only if it is a short sharp shock applied while containing the virus is still possible and accompanied by border controls to isolate the country from external sources. Otherwise, it’s unclear whether it really makes much difference, especially as it drags on and people become unable or unwilling to maintain the restrictions which make life too unpleasant or might even be impossible for some people with special needs to follow.
If reactionary lockdowns are not the correct approach, what are the alternatives? One might be to shield those considered most vulnerable while allowing the virus to spread through the rest of the population, but is that achievable when some people live in multi-generational households and others will want to visit elderly relatives? Another might be to impose limited restrictions (as Sweden did) to limit the possibility of super-spreading events in large gatherings while allowing normal everyday life to continue with people being careful. Testing more widely and isolating those found to carry the virus could help reduce the spread without locking the whole country down. However that relies on enough quick simple tests being available. One objection is that such tests might be insufficiently reliable, resulting in false positives and negatives. A false positive would require someone to isolate unnecessarily and a false negative might cause an infectious person to remain in circulation. However, that is looking at it from a perspective of individual liberties rather than public health. What matters for public health is to lower the infection rate, R, as far below 1 as practical. If R is around 3 when no measures are taken, isolating 67% of carriers is all we need to drop it to 1. Isolate 75% and it goes down to 0.75, enough to make the epidemic unsustainable. It wouldn't matter that a quarter of carriers were still spreading the disease as they wouldn’t spread it enough to keep it going. Of course, it would be even better if the test were more reliable. Equally, if we had 10% false positives, although that would take 10% population needlessly out of circulation, it would be far better than locking down 100%!
There are still a lot of questions to be answered, given the impact of the lockdowns on people who are vulnerable from other sources or have needs which are currently unmet because of the restrictions, and the possibility other strategies might be available and have a prospect of hurting people less deserves to be examined.
The problem is: none of us quite knows the answers to those questions, so none of us knows how to react.