I recently realised that it’s still about two strategies. Though it’s something I knew at the start of the crisis, I had forgotten it recently, but in discussion of ‘exit strategies’ and hearing an expert talk about coming out of lockdown I was reminded that there are, still, two different strategies available.
I wrote this as I thought this might be helpful for others to understand – certainly media discussion doesn’t seem to appreciate these options, but perhaps this is widely known or other people are writing about it anyway.
(This version is a shorter version of the piece, less than 1000 words. The long version, with more words about the strategies, trade-offs and economics, is here.)
Two Strategies
There are essentially two strategies to choose against the coronavirus – though, of course, with a spectrum between them.
#1 is to suppress and eliminate the disease. The aim is to have few enough cases – perhaps even none – that it stops being a problem. Some countries have done this, either by shutting down at a very early stage, like New Zealand, so that there is hardly any community transmission, or by having a lockdown for long enough that the numbers decline to a containable amount, alongside containment measures.
#2 is to try and keep transmission and the number of cases low enough that it is manageable within the healthcare system. If your healthcare system has, say, 1000 intensive care spaces, and capacity for 100,000 tests, then you might try and stay below 5000 with the virus and 800 intensive care cases so that everyone who needs it receives adequate healthcare support. (I should be clear those are basically numbers I made up.) Thousands will still die, significant social distancing is still needed. Mass testing and contact tracing would also be very useful measures to limit exposure and provide good information.
(There is also strategy #3, which is to do little and deal with the mess as best you can. I’ll leave it out, but some countries or places are doing it, through choice or lack of other options.)
Key to both strategies is to keen the reproductive rate, R, below 1.0. This is the number of people that each person, on average, spreads it to. If it’s above that, you get exponential growth of the disease, and a huge problem. The rate of transmission without social distancing was somewhere between 2.0 and 3.5 – hence cases doubling every two days.
Strategy #1 takes longer for countries, like the UK, who currently have a significant number of cases, requiring a sustained intense lockdown to get cases low enough. The benefit is that, if it works, relative normality can continue, though it may require reintroducing measures, either nationally or in a targeted way, but it may not be viable. Strategy #2 means a lifting of some intense measures soon, but that thousands will continue to die and a much longer time of significant social distancing.
Spectrum, Mixtures, Measures
Each of those are models or essences of a strategy, and most countries will be somewhere inbetween them. It will also be different within a country. Within the UK, for example, some small islands are going for #1, and it could be described that for care homes, little enough was done it was somewhere between #2 and #3. Sweden has, from loose reports I have seen, brought in some limited measures, but seems almost closer to #3 than #2.
Measures are distinct from strategy, but are often confused. We’ve become so focussed on one measure – ‘lockdown’ – that strategies seem to have been forgotten somewhat. The measures do not distinguish: lockdown can be part of strategy #1, or strategy #2; both strategies need R<1.0; both seek to avoid ‘peaks’ and ‘spikes’.
What Next for The UK?
Understanding these two strategies is, I think, crucial for understanding the next stage. I think that calling it an ‘exit strategy’ is a mistake: there is no exit, there is only short term, medium term and long term. The UK – and other countries in similar position – have two choices, between strategy #1 and strategy #2. The choice is about trade-offs.
The UK has always been pursuing a version of strategy #2. Though it gets obscured by the fact that we went into lockdown, the plan of ‘flattening the curve’ (even without the words ‘herd immunity’ attached, which were something of a distraction anyway) was our plan from quite early on. In the interview where Johnson said that one option was draconian lockdown and the other was to ‘take it on the chin, as it were’, he said that he wanted a balance between the two. The Chief Experts talk of flattening the curve, not of eliminating the disease. The clamour now is to reopen to some degree as soon as possible – not to eliminate the disease.
It may be that something closer to strategy #1 would be better: lockdown for longer, reduce cases much more before returning to some level of normality. I might vaguely guess this to be the case, but I don’t actually have anywhere near enough information to know.
The choice of strategy includes many unknowns or uncertainties, such as how well smothering the disease would work and how effective containment can be long term. But it also includes moral choices – ones that our Government is playing with – which are about trade-offs.
One trade-off is between ‘the economy’ and ‘lives lost to the virus’. This trade-off is a vile and evil one which sacrifices some people for ‘the economy’ and those who benefit most from it. Some have professed openly that we should sacrifice some people, but many more have said this implicitly.
There is another trade-off with ‘the economy’ though, which is morally legitimate, though difficult. This is between ‘lives lost to the virus’ and ‘lives lost to other things’ and ‘benefits to life from economic activity’.
Lockdown measures do have a cost that isn’t just financial. Other health conditions which cannot be treated while the focus is on coronavirus intensive care. There will be some economic effects which may cost lives, which I’ll return to. Lockdown itself will have effects, a form of iatrogenics; if it has significant effects on wellbeing, that will shorten lives across the board; and I don’t know if people are on the whole healthier, eating more healthily, sleeping better and getting more exercise in the current situation or not, but it could have a negative effect.
Economically, of course, there are questions of justice and distribution. The economic cost could be less if our economy was different, just as the economics of the last decade did not need to result in public services cuts and low wages for the poor while the rich stayed rich and got richer. As always, we should make these arguments, but with things unlikely to change anytime soon, and that the current Government is not contemplating this, this trade-off remains.
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Thoughts, comments, questions, disagreements and corrections all welcome. If you are an editor who might want to publish an improved version of this post (which was only written to my blog standard!), get in touch!