The Government recently published their Covid ‘roadmap’ setting out what their plan for lifting restrictions over the coming months. I thought I’d write this blog post as a way of thinking through how I think and feel about it, partly to get them out of my head. If you want to live in sunny optimism, maybe don’t read this; I don’t share that optimism.
Most journalistic coverage has pissed me off, and I mostly don’t engage with it at the moment. It’s all too sensational, short-term, disconnected. I listened to BBC podcasts which even claimed to not do this, but still did it. Missing is the proper analysis of the what is going on as a whole picture. This mostly seems to be a product of what journalism is about: grabbing people’s attention and ‘selling’ them a story, a version of what we now know as clickbait. Anyway, here’s my attempt to do better – though, y’know, it’s just a blog post, and I haven’t done any tricks to keep you engaged.
Overview
This post is a longer one, so I thought I’d let you know what it contains, and you can always just read the parts you want to.
- The two different possible Covid strategies, and the story so far of the Government’s response in delaying lockdowns and easing measures too early
- What a Zero Covid strategy means and would look like
- Summary of vaccine efficacy
- Analysis of the ‘roadmap’ easing of lockdown restrictions plan
- Effect of vaccination programme on the spread of the virus
- Conclusion on the Government’s approach
- The International Dimension
- Vaccine Resistant Covid
- Finishing Thoughts
Two Pathways, and the Story so Far
As I wrote last year (sigh), there are two options for how to deal with Covid. There is the ‘strike a balance and live with it’ strategy and the ‘zero covid’ strategy (the third option of ‘stick your head in the sand and pretend it isn’t real’ has typically been abandoned after a short while).
In my view, the Zero Covid strategy is the only sensible one. As for why this doesn’t happen, I think a significant part is a lack of emotional maturity, self-reflection, and will to actually go through through with difficult decisions of various people in power: the Government, other politicians with power, the media, and all the rich important political actors who are trying to push things their way.
The ‘live with it’ strategy is the one the UK have been trying. Lockdowns are implemented when the virus is out of control (usually after a significant delay), and lifted when the transmission etc of the virus is low enough. Last summer is when the Government faced the choice of which strategy to go for, and they decided to lift restrictions as soon as they thought they could get away with it. It was unthinkable in Government to consider that there might be a second wave and further restrictions needed, they literally refused to contemplate this and plan for the possibility, and then when it started happening, tried to pretend this wasn’t the case.
R was greater than 1, on publicly available data, for the entirety of August, but case numbers were small enough that it only changed from 500 daily new cases to 1400 new daily cases in that month. Then, come September, the addition of return to school increased transmission, the Government ignored scientific advice to lockdown hard and early, tried to do a regional tiered system, and ended up needing a longer lockdown. The November lockdown got partly lifted in December: at that time there were about 14,000 new daily cases, the same amount as when the November lockdown was began. All the lockdown did was ride out the peak of a wave, not get cases actually low enough. That decision to lift it necessitated the short-notice ‘cancellation of Christmas’ for many (and chaos that came with it) and the January lockdown. It took us until mid-Feb to get back to the situation we were in at the end of November. It is deeply frustrating that things could have been different, and there is nothing we can really do with that frustration, no healthy way to process it and turn it into something else.
(And that isn’t to mention the various other problems with how the situation has been handled: inadequate financial support; chaotic messaging; short-notice announcement and plans; undermining public trust; strange scientific advice by not emphasising the airborne nature of the virus; and probably more besides.)
As for the current situation, the Government’s roadmap strategy is still a version of the ‘strike a balance and live with it’, with two differences. One is that they are leaving longer between restrictions are lifted, so that the effect can be seen before the next stage is reached. That being said, I don’t have much hope that they will hold back when they need to, given how they have failed to do so already and that the roadmap is already lifting measures too soon – more on that to come below.
The second is the vaccine rollout. The first part of this is that elderly and vulnerable people, and workers in health and care settings who are both at personal risk and transmission vectors, are already vaccinated, which reduces the effects of Covid to these people (and some effect on wider transmission). Secondly, that later in the year, the public at large will be vaccinated, with the target of ‘first dose for all over 18s by end of July’, meaning that we will have a fairly good herd immunity to Covid, with vaccines on top of the 20% or so of the population who have had Covid. However, this second part won’t be relevant in time. More detail on vaccination to come.
A Zero Covid Strategy
A Zero Covid strategy is one which aims to get Covid case rates and transmission down to an effective of zero such that it can be suppressed. In reality, perhaps <100 per day in England is about the target. With cases that low, everyone can live in a pretty normal way most of the time, but there would need to be (a) an effective testing and contact tracing system, (b) intense, localised measures whenever Covid spreads, and (c) effective mandatory quarantine for any arrival into the country.
It might sound far off, but that is because the UK situation has been fucked for almost a year, so it is almost unimaginable for us. China, Australia, New Zealand and many Asian countries all have Zero Covid strategies, and they are working fairly well. Roughly speaking, life goes on as normal (pre-Covid normal!), but if a Covid case is detected – usually through staff at a quarantine hotel – then there is intensive contact tracing, testing, and a severe local lockdown at a day’s notice. New Zealand had the fortune of being an island that never got hit hard by Covid, but China and Australia both went into a Zero Covid approach after significant outbreaks.
Zero Covid would work something like this
- (Get cases very low)
- When Covid is detected, clamp down hard. That might mean an absolute local lockdown if there is a case in an area – which might mean a whole city or region. This might mean that people get stranded from going home or to their family, if they are out of that region, and people would be cut off from work in many situations too.
- There would be a thorough testing and contact tracing system to try and catch the entirety of an outbreak. Zero Covid only works if it is nearly 100% contained, whereas the current ‘test, track and trace’ approach which is only trying to mitigate the spread but not entirely suppress it.
- Anyone entering the country, or potentially even travelling between regions or countries, depending on how you segment it, has to go through a 14-day quarantine, as well as a series of negative tests. (Testing is far from 100% – for example, if someone has picked up Covid but it hasn’t yet developed, a test won’t detect it, or if the test is just not done properly – so cannot be relied on to be 100%. 14-day quarantine plus double-test seems to be enough though.)
- Outside this, life can carry on as normal. The ‘balance’ measures aren’t needed. New Zealand can go from cinemas and parties and concerts to a lockdown in a couple of days, then once the spread is contained, can reopen.
This does mean that day-to-day, you don’t know if a lockdown of some sort is about to be immediately imposed, but I would take normality interspersed with random one or two week lockdowns over many months of mostly-lockdown. And that’s without the other benefits tjhat come with it! As I will talk about more in this post, a Zero Covid strategy would also:
- reducing the impact of removing restrictions in terms of people catching Covid and either dying or getting Long Covid;
- mean getting back to a more ‘normal’ way of life in the medium-term;
- be much better internationally, reducing the spread of Covid to other countries from the UK;
- reducing risk or pace of vaccine-resistant Covid variants.
Of course there are people who don’t support a Zero Covid strategy, but I don’t think it’s had a full consideration. Part of the dismissal is this idea that it ‘wouldn’t be practical’, but much of this I think this is a refusal to face up to the reality that Covid might entail. Last year the Government – and probably most people – thought that it would be over after the first wave, and I think there is a similar feeling again now.
Vaccinations – Small Scale
The UK vaccination programme has been going very well. Getting the first dose of the vaccine alone is pretty effective for reducing death and serious illness, though the effect does depend on age group: young adult health workers got 70% protection against mild disease; over-80s had 55% protection from mild disease. They then have a further reduction of at least 50% from mild disease into hospitalisation, so for young adult health workers that totals about 85% protection and for older adults about 75%, from one dose. The vaccine does not prevent someone getting infected: it means that when they are infected, there is protection from the disease because their immune system deals with the virus before getting overwhelmed. The second dose is important to lock in longer-term protection, as the protection from the first dose fades after some months. [Sources here, here, here and here.]
Vaccination also reduces transmission to others a fair amount, but whereas it has a significant effect on transmission in public given masks and distancing measures, my guess is that it only has partial reduction in transmission between people in close contact. Between two people who are a couple or perhaps even live together, if one is vaccinated and goes out and about with lots of exposure, they could still pass it onto the other. [Source here.]
This scientific understanding hasn’t, I don’t think, fully permeated into the general population enough yet. Many people think of masks as “safe” – I’ve had a couple of people, who wanted extra protection when meeting up, say that I didn’t need to wear a mask because they were wearing one. The Government’s use of the language of “Covid secure” is a big part of the problem too, treating some transmission reduction measures as if they provided complete safety. I worry that the same thing will happen for vaccines: that people will see vaccinated people as “safe”. It is crucial to understand the vaccine as a ~ 75% reduction in personal risk and transmission risk, instead of a complete safety. I worry that people who are vaccinated will still pass it onto others, or that people will visit their vaccinated relatives and still pass on Covid to them.
Easing Lockdown Too Soon?
I wanted to run some rough modelling to help me think it through.
November lockdown:
| 11th Nov | 27th Nov |
| 24,623 | 14,500 |
That’s about 16 days to almost halve case numbers.
| 1st Jan | Jan 10th | 22nd Jan | Jan 26th | 7th Feb | 12th Feb |
| 61,263 | 46,654 | 29,297 | 23,964 | 14,359 | 12,251 |
These numbers again suggest that the halving time for Covid new cases is around 16 or 17 days, for example, Jan 10th to Jan 26th, or 22nd Jan to 14th Feb, or Jan 16th to 12th Feb.
By Feb 25th we made it to about 10,000. By end of March we might be on 2,500. As of 8th March, we’re on about 5,000 new cases per day.
For some benchmarking:
- mid-September case levels of 5-7,000 were when SAGE recommended going into lockdown;
- 1,400 was the number at the start of September when schools reopened.
On 8th March, schools reopen, which will significantly increase transmission. I don’t know the data or models for how much it increases transmission, but I do remember that during first lockdown, SAGE advised that they did not think it possible to reopen schools while keeping R below 1, and I have also remember hearing that Scotland isn’t doing a full reopen of schools yet because their advisors do not think it safe to do so.
Additionally, now that it is allowed for people to meet up outside 1:1 to sit somewhere, that might also increase transmission. I don’t know how much transmission there is between two people sat one metre apart (realistically, I don’t think most people do sit two metres).
So transmission will increase, and the reduction in cases will slow down. Potentially this might even be enough to tip R to being back above 1.0. No social indoor mixing between households is planned until 17th May, when the ballpark I’m estimating is between 2000 and 500 new cases per day. That being said, people might start doing it sooner; it’s been a long time, and people seem not to follow the partway measures in the way that they follow ‘actual lockdown’.
From the numbers above, it very much seems like the Government is still going for the ‘balanced’ approach of lifting lockdown measures as soon as they think they can get away with it, instead of waiting until it is properly safe to do so, or less harmful or less risky. I note that the chief advisors did not support the Government’s roadmap approach [and since drafting this, further reports have come out confirming this, for example.
So, waiting another 2.5 weeks before lifting measures – getting cases down to 2000 instead of 5000 say – would mean that half as many people catch Covid (and die, or get long Covid, and the disruption from catching Covid, etc) in the next period. It’s a difficult trade-off to make for sure, but the Government do seem to be lifting things as soon as possible, instead of holding their nerve to get more safety.
One of the significant thing – perhaps even the main thing – that the Government is focused on is whether the NHS becomes ‘overwhelmed’. Where this point is is more like a spectrum than a single tipping point,starting with regular services being affected and, at worse case, hospitals unable to accept new people. In the middle is a lessening of the quality of care, such as intensive care ratios becoming 1:2 or 1:3 instead of 1:1.
The Effect of Vaccination
As you may have been thinking while reading that previous section – ah, but what about our world-leading vaccination programme? I presume that the Government is banking on the effects of this outweighing the increased transmission of cases.
Key at this stage is that the people most likely to die from Covid, elderly and clinically vulnerable people, have received their first vaccine dose. That reduces deaths within this much more at risk group – about 30% of the population – by about 80%, so deaths may well stay low even if cases do rise. However, as far as I know, anyone can be affected by Long Covid, which has serious long-lasting effects. Personally, I’m much more scared of this than of being killed by the virus.
Let’s turn to the broader public health effects of the vaccine rollout. There have now (end of 7th March) been 22 million first doses, which is about 30% of the population. Transmission of Covid is reduced by perhaps two-thirds by the vaccine, so that’s a 20% reduction in transmission among the whole population due to the vaccine so far. That does give more breathing room of activity before R>1.0, though as under-18s do not receive the vaccine, the transmission from schools won’t be changed.
There are about 2.5 million doses per week. So by 12th April, that will be another 5 million doses, which gets us to about 40% of the population. By mid-May, when indoor mixing becomes allowed, that will take us to about 47% of the population. That being said, second doses might well slow this down, effectively halving the rollout of vaccine protection, so we might only be on 40% by mid-May. To be fair, about 20% of the population are children, so about half of adults will be covered by this point.
I don’t know enough to know whether the increased capacity from vaccines will contain the increased transmission of the virus or not. But it seems like a risky balance, when instead, we could play it safe. Even if the most vulnerable are protected by the virus, if the transmission rate is over 1, then because it is exponential, it will effectively be let loose through the population unless distancing measures are reintroduced.
Conclusion on Easing Measures
So, it seems to me that the balance is being struck in the wrong place. Waiting a bit longer and holding their nerve would make the exit of lockdown easier, reducing impact of the virus and with more safety room to change course. Building on that, I would still very much prefer a ‘Zero Covid’ strategy.
With ‘everyone over 18 having the first Covid dose’ only 4 months away, it isn’t long until there is herd immunity. Instead of this phased reopening from now until May, why not just hold off until sometime in May when there would be less than 1000 Covid cases or fewer? Surely that would be a more sensible balance to strike?
I want to be out of lockdown as much as the next person. That’s a rhetorical overstatement; I am sure there are people in a worse situation than me who want to be out even more, but you get the point. The gist is: I am really not enjoying this. But, once cases are lower, a wider and safer reopening would possible. What would be much worse is spending the next few months doing a lockdown hokey-cokey, lifting some measures but then reintroducing them as case numbers rise. It could well be that, come May, cases have risen enough due to the partial lifting of restrictions that we need to go ‘back into lockdown’ (even though at that time, mixing indoors socially would not yet have been allowed).
Emotionally… I have mostly left the emotions out of this post for various reasons. I want the situation to be over. It’s horrible, it’s isolating, the isolation and all of the interferences are bad for so many of us. I’m frustrated and angry and sad at the Government and how it is being handled, and there’s not really anywhere to put that. We’re all exhausted. It would be nice to be optimistic about things getting back to normal, but I don’t think it’s that likely; what seems likely to me is that cases increase again, then they revert back to more lockdown, or they open up anyway and are in denial, and maybe that means having to they revert back to more lockdown until there is enough vaccination. Without the optimism or the trust, it just feels like it will be bleak for the next half year or so, and I think that I’m being numb to that to avoid feeling sadness or despair or whatever would come from engaging with the idea that this might actually last for another many months… And even if it does lift in the UK, what about the friends I have in Germany who I haven’t seen for two years now. Speaking of which…
International Dimension
The UK has, for various reasons, got further ahead on vaccine rollout than some other countries. Assuming all goes well, after the summer we will have herd immunity with a vaccinated (adult) population. Restrictions will be lifted, and Covid will be circulating around the population, but with much less effect. I don’t know the numbers for what amount of circulation of the virus is tolerable, for whether the 75% reduction in transmission and 80% lower rate of serious illness is enough to stop exponential spread or an overwhelm of healthcare services, but it feels like it could go either way. As Covid can be spread without symptoms, either pre-symptomatically or asymptomatically, anyone could be carrying it.
Internationally, if we have a vaccinated population with Covid spreading through the population, that means we pose a risk to other countries which do not have vaccinated populations, which is to say, the majority. Countries with Zero Covid strategies will probably still need to stop vaccinated people from the UK from entering, and countries who are taking the ‘balance’ approach might need to bar (or quarantine) us from entering too. The number that was being used to determine whether someone could enter the country was if they were coming from somewhere that had lower than 20-50 cases per 100,000, around 0.05%. I would guess that a vaccinated UK which doesn’t have many measures would exceed this, even if the majority of these cases do not have symptoms and are more-or-less fine for the person infected with the virus.
This is the large-scale equivalent of the idea that just because someone is vaccinated doesn’t mean that they aren’t still a danger for everyone else. And I haven’t gone into detail here because I’m not a scientist, and if you want to know more you can look it up. It just seems to be something not being taken into much consideration as part of the Covid response strategising.
The point I want to make is that Zero Covid allows for connectivity. Covid is a global, international problem, not a national one. The social construct of borders is fairly irrelevant to the virus. The UK’s strategy is a national one, not part of an international one. Zero Covid strategies therefore reduce the impact internationally significantly. This has, sadly but predictably, not been a significant part of the discussion, which has almost entirely been about national self-interest.
Vaccine Resistance
There’s another, very good reason to pursue a Zero Covid strategy: the more the vaccine is in transmission, the more mutations there are to produce variants which could be more transmissible, more deadly, or vaccine resistant.
When taking antibiotics to deal with an infection, it is widely known that it is important to continue the whole course of antibiotics. Even if halfway through the symptoms are reduced, stopping antibiotics there would mean that the bacteria remain are the ones that are more resistant to the antibiotics, which reduce the effectiveness of antibiotics over time.
In my vague understanding, this is the same with diseases and vaccinations. If a significant proportion of the population is vaccinated, this will screen out most of the virus, but not virus variants which the vaccine is less effective against, which would then spread. In effect, having some level of transmission in a population which is part-vaccinated could just mean that only vaccine-resistant Covid gets through. Vaccination should really be done in a quarantine of sorts to avoid this, getting to Zero Covid… which is the opposite of the Government’s ‘strike a balance’ approach.
There are already some variants which the vaccine is less effective against. This is a problem we already have, and will only get worse. I don’t want to smash even more of any optimism people might have, but this might well not be over by this summer, or even the end of the year. It could continue to move around the world, mutating, infecting people a second time or bypassing some of the vaccine resistance we have. Repeated vaccination programmes, like the annual flu vaccine, are already being discussed – but these might only be possible in western countries, not globally.
So, that’s another reason why a Zero Covid strategy would be better: reducing deaths; more certainty going forward; better internationally; and reducing the change of vaccine resistance.
End Point
This isn’t a happy post. I was going to continue that these aren’t happy times, but I don’t like that narrative. We might pretty much all be affected by the pandemic, but it’s wrong to assume that it’s everyone’s worse year. Certainly 2020, even with the pandemic and isolation, wasn’t among my worst years. And that narrative also encourages us to give up, putting life on pause until after. I firmly believe that we should make the most of what we have, live the fullest and most meaningful life we can, within the constrains that we live in. If you want something to read more along those lines, here’s a blog post I wrote on that theme. Otherwise, all the best.
In love, care and solidarity,
Alex.
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Also – I am not an expert on viruses. I have set out my reasoning here, and hopefully been vague enough about the vaccine resistance virus possibilities that it is clear I am not speaking as an expert. If you read this and there is a mistake, please let me know, either by comment or messaging on whatever platform you saw this on, or by dropping me an email.