Controlling Covid-19: lockdown, or let rip?

This week we’re discussing how we get out of the Covid crisis: let the virus go and nature take its course, or continue to attempt to suppress the spread but at great cost to livelihoods, education, well being, freedom and the economy...

Chris - Worldwide, we estimate there have been close to about a billion coronavirus cases, and at least 1 million people that we know of have lost their lives. Some countries, Australia being one of them, have controlled the virus very well. Across Europe though, outbreaks are surging again, and many countries are re-introducing significant restrictions, such as curfews in France and Spain, tiers in England, firebreaks in Wales, and some are even calling for another total UK lockdown as we attempt to control the spread of the virus. That's something though the government has so far resisted doing.

Boris Johnson - There are those who say we need now to lock the whole place down, from John O'Groats to Land's End, turn the lights out, shut up shop, close schools and universities, and go back to the same kind of lockdown we had in March and April and May. And I have to say, I don't believe that is the right course now. Not when the psychological cost of lockdown is well known to us, the economic cost and not when it's being suggested that we might have to perform the same sort of brutal lockdowns again and again, in the months ahead. And not when there is such an obvious variation, unlike last time, between different parts of the country. So that's why we're going for a balanced approach, a middle course between the scylla of another national lockdown and the charybdis of an uncontrolled virus.

Chris - But is it the right balanced approach? That's what we're going to find out. That was the UK prime minister, Boris Johnson there. Now many are still very unhappy about the actions that are being taken, arguing that they infringe on our civil liberties, they're economically ruinous, they'll prove more costly in the long term on many levels than allowing the virus to spread more naturally. The pill, they're saying, is worse than the ill. Now, early in October, one group authored the Great Barrington Declaration advocating an alternative approach that was based on what they called focused protection of those most at risk and thereby minimising the broader societal harms of the Covid-19 pandemic lockdowns. The World Health Organisation on the other hand, despite advising against lockdowns have described that strategy as dangerous, unethical and lacking in a sound scientific basis. Writing in the Lancet medical journal, another group of researchers have set out what they're calling the John Snow memorandum, arguing why taking our foot off the brake and allowing the virus to spread is the wrong approach. This is what Boris Johnson had to say about the issue in a recent Downing Street press briefing.

Boris Johnson - I know that there are some people who say this economic objective is so important that we should stop all measures to control the virus and stop restrictions of any kind on our social lives and on the way we run our businesses. We can't do that because, alas, the maths is inescapable. We would face many thousands more deaths and no, to answer one commonly posed question, we would not be able to insulate the elderly and the vulnerable, not in a society with so many multi-generational households. No country has been able to do that. And an uncontrolled expansion in the number of Covid patients would mean that the NHS would have even less capacity to treat heart patients and cancer patients and to deal with all our other medical needs. So that's why we reject that extreme laissez-faire approach.

Chris - What is then the best way to walk this tightrope between the cost of civil liberties, the economy, education, and the future prosperity of the country, balanced against the risk of loss of life? Well, that's what we're going to try to discuss over the next 25 minutes or so. And with me to do that are Deepti Gurdasani, she's an epidemiologist from Queen Mary University of London, also Angus Dalgleish a cancer doctor at St George's Hospital University of London, Phillip Clarke who is a health economist at the University of Oxford, and Richard Parker who is from the University of Connecticut School of Law. So hello to all of you.

Deepti, if we may begin with you, can you just sort of summarise for us where we are numbers wise at the moment, where are we across the world? And in the UK specifically?

Deepti - Worldwide, we've had over a million reported deaths from Covid and this is very much likely to be an underestimate. Within the UK we've had over 58,000 confirmed deaths as a result of Covid-19 and at the moment we're seeing exponential, so that's very rapid, rises in cases. We are currently at about more than 20,000 confirmed cases a day, which again is likely to be an underestimate because we've reached testing capacity and we are seeing around 200 daily deaths, with them approximately doubling every two weeks.

Chris - And how does that compare with the other thing that we see a lot at this time of year and that's the flu? So in a bad flu year, how many deaths would we normally get from the flu in a country like Britain?

Deepti - Nowhere near what we're seeing with coronavirus. I mean, usually I think it's under 20,000 deaths that we expect and definitely flu does not rise at the rate that coronavirus does because a lot of the population is immune. We have a vaccine against flu. And also we know that flu doesn't spread as rapidly as coronavirus. Flu also has a much lower risk of people dying when infected, compared with coronavirus. The rate of dying with coronavirus is several fold higher.

Chris - The thing is though that if we look at the death toll in the UK every year, about 600,000 people die in the UK every year, don't they? And the fraction that is coronavirus deaths at the moment is single numbers of percent, maybe 4%, I think is one number that's been listed for September. So it's actually a very small proportion of the overall death toll in this country.

Deepti - Yes. And that's because of all the measures that have been taken to control it, it's actually well accepted in the scientific community that if it was allowed to spread in a susceptible population, it would lead to hundreds of thousands of deaths, more in the range of about 300 to 400,000, if it were allowed to spread. Because unlike many other causes of deaths, they don't actually expand exponentially. So for example, people talk about deaths due to road traffic accidents, but road traffic accidents don't multiply over time. With coronavirus, if a person is infected in another five days you'd have three people infected in another five days you'd have nine, and then 27 and so on. So the potential for causing death and infection is huge.

Chris - But it's not an equal opportunities virus in terms of age, is it? Because it's not a valid comparison to say, well, road traffic accidents, because actually the people that have the most to lose from this virus are the people who are the oldest in society.

Deepti - Yes, definitely the fatality rates are higher in older people, but we know that young and healthy people can get long-term effects. Things like type one diabetes, which can lead to permanent or long-term effects. We don't know yet. So it's not just that old people are vulnerable. We know that people who are, let's say obese or people who have diabetes, hypertension - so this is about 20 to 30% of the population in many countries - are vulnerable to what we call severe Covid-19 disease. So it's not true that this is a disease that mostly just occurs in older people and doesn't affect young and healthy people because it certainly does.

Chris - Thank you Deepti for that overview. Let's bring in Richard Parker at this stage, Richard, I appreciate that you are a law person rather than an epidemiologist, but what's the situation across the States at the moment?

Richard - Well, greetings from America where we have 8.6 million positive cases diagnosed to date, 224,000 deaths, we have 4% of the world's population and 20% of the deaths. We have new cases rising at a rate of about 80,000 per day, which is more per day, even on a population adjusted basis than New Zealand experienced in its entire pandemic trajectory for the year to date. So we have not handled the pandemic well, and we're having very much the same kinds of discussions here in the United States that I hear you're having in the UK.

Chris - When you say you've not handled it well, you can only really say that if you have a comparison. So what are you comparing it to when you make that judgment?

Richard - Well, that's been my area of research. I compare the US response to the response of the benchmark practices and results set by successful countries like New Zealand, Australia, Korea, Taiwan, China, Japan, Vietnam. These countries have handled this much better, just following the pandemic playbook. And what you find is that if you just look on a population adjusted basis at the number of deaths per capita in these countries, our death rate is many times higher than theirs. And you can actually calculate how many Americans would still be alive if we'd handle things as well as New Zealand. And that number is over 200,000 who would still be alive who are now dead. If we'd handle things just as well as Canada, over 130,000 Americans who are now dead would still be alive. So there was a tremendous price to be paid. And all the evidence shows that the response that countries take to the virus determines how many people die. It's just a matter of following the playbook. And I would also note in closing that these countries that have actually eliminated or conquered the virus are now able to reopen. Life is going on more or less normally across most of New Zealand, with precautions, but at a much higher level of economic activity. The same is true in China. The same is true in Japan and Korea. So it's not a matter of, you know, opening the economy versus defeating the virus. If you defeat the virus, you can open your economy quickly.

Chris - But you mentioned countries that actually have had a good track record. Vietnam is one of those countries that has a very good track record. We also spoke to one of your fellow countrymen, Todd Pollack. Now he's an infectious diseases doctor from Harvard, but he's based in Vietnam. So what did he think, we asked him, made Vietnam so successful in controlling their outbreak?

Todd - Not one intervention alone is enough to contain Covid-19. The key to Vietnam's success is that they did many things that are proven to be wise policies. And they did them earlier than most other countries. Some of the key interventions were a very effective and comprehensive contact tracing program. Having rapid responses to contain clusters of outbreaks, such as locking down entire villages or neighbourhoods. Increasingly strict border control policy with very early mandatory quarantine for all arrivals, early recommendations and requirements for mask wearing, and a communication strategy that unified and mobilised the population to do its part to control the virus.

Chris - Is that basically, Richard, what is wrong with the response in countries like the UK? Countries like the US?

Richard - I haven't studied the UK, but I can say that that is a perfect summary of what went wrong in the US. And if you compare the way we handled the virus on all those points, contact tracing, testing, isolation, travel restrictions, dramatic contrast at all those points between what the US did and what New Zealand did and Australia did and Korea did. And I think that accounts for the difference in results.

Chris - Thank you, Richard. I want to bring in Angus at this stage, Angus Dalgleish is a cancer doctor at St George's. One of the big worries here is that while we prioritise the health provision to try to cope with coronavirus, we are potentially storing up this enormous clinical iceberg of people out in the community who might not be seeking treatment. They might have treatment deferred. They might have missed treatment. They might not be having screening that would pick up treatment. They might not be having vaccines that prevent ultimately cancers. For instance, the human papilloma virus vaccination programme has been interrupted for some girls in some schools. Is this really your concern, that basically we're robbing Peter to pay Paul clinically here?

Angus - This is a major concern, I believe, and it has been grossly overlooked -  that the number of patients who have missed screenings are in the millions. The number of patients who have had their diagnosis of cancer deferred... And I know personal cases, and I've seen those who've been deferred, they've been deferred to have their procedure, their biopsy, by two or three months during this pandemic; and then when they get it they're now stage 4 cancer, and they're going to last months, whereas they were curable. And there are thousands of cases like this. And it's not just cancer; the same goes for heart attacks, strokes, all these things, and that's before we get onto the mental health problems. The knock on effect of this is enormous. And for those who like to speak in figures, we've only just gone over 40-odd thousand people who have died of this virus. In the first two months of the pandemic, in April and May, the death rate was of course a lot higher - we had a crisis, and the lockdown was the right thing to do - but after that was controlled, the death rate actually went down. And so basically this showed that the pandemic basically brought forward deaths that were going to happen anyway. And I think when you look at it, this is very clearly what's happened. It's a very interesting virus. It has replaced, actually, the flu; let us not forget the flu killed 28,000 people in 2015, and if you actually look at that 42,000 figure, quite a few thousand of those are probably not people who died of COVID, but had had a diagnosis of COVID. So I think we have to be very, very careful. Whereas we're not hypothesising about the tens of thousands of people who are going to die early of cancer, and many of these people are in their thirties, forties, fifties; they're economically productive. Whereas most people who are dying of COVID -  the majority are in their eighties and nineties, and no longer productive.

Chris - There was a letter written to the Daily Telegraph yesterday -  "Letters to the editor. Sir, it's impossible to prevent death. The best anyone can expect is that we can postpone it for as long as possible while we have a reasonable quality of life. The government has decided that it can postpone some deaths by imposing draconian restrictions on people, to the detriment of their quality of life, while bringing forward a significantly greater number of deaths than those they're trying to postpone." Is that sort of what you're arguing, that basically we are actually going to store up a pill that is worse than the ill, as some people are saying, with this sort of measure?

Angus - Yes, I saw that letter and I totally agreed with it. And if you go through the letters to the Telegraph for the last two to three weeks, there is an incredible outpouring of people who are in their eighties and nineties, at risk, who are basically saying that they would far rather take the risk and have a normal life... they know they haven't got that long, but the last thing they want to do is spend their last few years in lockdown, unable to see their family, unable to have a normal social life. And this is what brings in this terrible mental angst, because even my own colleagues have committed suicide, let alone people outside. I subsequently found that my friend's GP's committed suicide. And you've seen the number of people locked in halls of residence who've been found dead. The knock on effect is so enormous. You cannot justify another lockdown.

Chris - Philip, you're a health economist. I suppose one of the big problems that the government have to balance here is that on the one hand, an epidemiologist like Deepti comes and answers a question, which they're asked, "how do we minimise the deaths from COVID? What are the risks? What's the potential death toll?" And then you have an oncologist like Angus, who's saying, "well hang on a minute, we're actually already seeing very profound numbers of deaths in society for other reasons." How do they make those sorts of judgements and turn this into a policy that is not just justified, but also meets the ethics and meets the economics?

Philip - Yes Chris, I mean economists have been working on what's known as a QALY, which is a 'quality adjusted life year'. It takes into account, say, how it might extend someone's life, but also how it may impact on someone's quality of life. And this has been routinely used in the United Kingdom for many years and in the evaluation of many different types of interventions. In the case of the lockdown, there has been some efforts, but some of the broader questions - which I think here, where we're trying to balance off the impacts of the lockdown on reducing the risk of the COVID-19 virus, versus the impact on other treatments - this hasn't been done. And perhaps it really needs to be done to make evidence-based decisions to balance off the benefits to reducing this infectious disease, versus the cost of many other diseases, and also people's mental health.

Chris - I'd like to play you a clip from Quentin Grufton, who is an economics professor at ANU, the Australian National University - one of your countrymen! And we asked him why, in his view, the lockdowns that have occurred in Australia have been so successful compared with, say, the UK?

Quentin - Some people say that you need to open up, get away from lockdowns, to save the economy; it's absolutely not the case. It's certainly not the case in Australia and many of the economies that I've looked at. When you get to low numbers, the payoff is that you don't have a lockdown! You go to New Zealand right now, it's like pre COVID. You go to Western Australia, it's like pre COVID. That's a huge payoff for the economy. And then you can manage the infections that maybe come out of quarantine, for example; you can manage them effectively through testing and contact tracing. But that's a payoff. I can tell you, Australia and New Zealand are going to do a lot better than the United Kingdom, and why? Because they went early, they went hard, and they've actually been able to get this virus and this infection under control. Those countries that have failed to do so are going to suffer not only in 2020, they're going to suffer in 2021. So a failure to act, a failure to act soon enough, is going to generate bad outcomes in public health, but also in terms of the economy.

Chris - That's the other way of looking at it, of course, isn't it -  that we spend a bit of money up front, and actually there is a long term benefit. There is going to be a health cost, we are going to rob Peter to pay Paul in the way that Angus was saying, but actually the pain will be less than if we carry with this cycle of boom and bust. Philip, what do you think?

Philip - That's certainly been an argument that many have put. I think it involves policies that are obviously quite draconian, and these occurred in New Zealand and Australia, but also these are island nations; and then you've basically got to close your borders. And so for example, a country like Australia is only accepting a few hundred passengers from outside, and only Australians are effectively going back to the country. In Europe I think that would be extremely difficult, to close the borders. It's an interesting question for the UK, but that would have to be a part of a decision. Part of this involves a bet on whether there will be an effective vaccine and when that would occur, which would of course potentially mitigate the current second wave, as it were. So it's a very difficult and uncertain policy environment. You can see why there are many different views about the ultimate sort of costs and the benefits of lockdowns in these circumstances.

Chris - Speaking about the whole concept of a lockdown though, the policy is that we have a lockdown, it buys you important time. It buys you breathing space to implement some kind of strategy that you have to have in place things ready to go, having come out of that eye of the storm that you create. Richard, so have we missed the boat for instance, in the US and also in the UK, have we fiddled while Rome and in fact, London and New York, have burned?

Richard - Well, I think that's a very good way of describing it actually. Lockdowns are part of a larger strategy that include contact tracing, testing, isolating people who get the virus, healing them and keeping them from transmitting the disease, and ultimately breaking the chain of transmission. If you do a lockdown really, really effectively and correctly as the successful countries have done, you can break the chain of transmission and you can do it quickly. And that is the compact that Jacinda Ardern made with her fellow Kiwis in March. She said, if we do this hard and we do it now, we can lick this virus in a month. And that's exactly what they did, it took a little bit more than a month. They were able to not only block the chain of transmission, but they were able to get in place procedures for contact tracing and testing that can contain any future outbreaks. So that is a social compact that a lockdown entails. Go hard, do it effectively, and it will be short -  but they did it really effectively and really hard. They had a population equivalent of 23,000 US prosecutions for violations of their lockdown. And so the other lesson from all of this is that you can't fake a lockdown. You have to actually do it. And if we'd actually done it harder in the United States and harder in Great Britain, when we were actually doing it, I think we would be done with the virus by now. There would still be obviously pockets and outbreaks that we would have to monitor against, but we would have a much, much lower base of cases and the economy would be reopening again here as it is in New Zealand.

Chris - Angus, if I could come to you, because you made the point that obviously this is storing up a lot of trouble, and it's going to cost a lot of lives in other respects. What would you do differently then?

Angus - I wasn't against the lockdown at the start. I mean, the lockdown was the right thing to do, and it didn't work here in the UK. It worked in New Zealand, but I mean, New Zealand is so completely different from anything else we have in Europe that they had that chance. But this virus is not going to go away worldwide. You're basically going to have to shut down all trade, everything, if you're going to completely lock it down like New Zealand and let nobody in or out. We will lock down until we die, and we will destroy the economy. If you're really going to try to get rid of this now, it's just not possible. I also think the epidemiologists have got it really quite remarkably wrong in many of their predictions and everything about it. And it's made worse because of the testing. The lockdown might've been a lot more effective if we had track and trace. And we just know the fiasco that that is, we still can't get that right. But as regards to the incidence of it, they worked from the wrong figures - they say it didn't come into the country, that it started on the 29th of January. I mean, I've got friends who clearly had it in mid-early December. And I knew they had it because we've had them tested and they're antibody positive.

Chris - What is the point you're therefore making? That in fact far more people have had it than we think and therefore it's less dangerous than we think?

Angus - Absolutely. You've got it in one. I know an enormous number of people who've clearly had it and they haven't died. And in many ways this is probably going to be the biggest problem, you know, the long term effects in young fit people. I think that's a far bigger problem than deaths which seem to be confined to people who are most likely going to die at any rate.

Chris - Returning to the point I put to you then, which is what would you like to see as the optimal way to manage this now?

Angus - The optimal way to manage this now is very much a mixture of the Swedish model and Barrington declaration, et cetera. That is those people who are known to be at higher risk have got to be very careful and shield themselves. And they've got to take a major role into it. But otherwise people have to get on with their lives and just beware, you've got to change the modus operandi. Remember Sweden was not a lockdown, but it did everything else. And the high death rate is quoted as this doesn't work. Sweden's high death rate was because they did the same stupid thing as the NHS and sent all the old people into care homes without testing them. So the high death rate in Sweden is all old people. Let us look at the death rate in Sweden in one year's time, because I think by doing what they're doing, they're not going to get the wave after wave that we are going to induce from having lockdown after lockdown

Chris - Deepti - this seems like a good one for you then. One of the points that Angus raises is the fact that there might be reason to doubt the severity of the infection and certainly the mortality rate. And in fact that's interesting because there was a WHO bulletin recently, wasn't there, a co-authored from Stanford, where they looked at the infection fatality rate. In other words, the people we know have had it, the people we know have had it and died of it. And those numbers, looking across tens of countries, seem to suggest that the mortality rate is about 0.2% over the age of 70. And in fact, if you look under the age of 70, it's 0.5%, which is less than the flu.

Deepti - Those studies that you're referring to have been widely discredited in the scientific community and are based on very, very selective evidence from certain studies. I mean, I guess just to give an example, if you consider that 58,000 people within the UK have died of COVID-19, which is what the Office of National Statistics say. And the IFR is, as you say, 0.05%, you would need, I think 120 million people to have been infected, which we know hasn't happened because the population of the UK is only around 66 million.

Chris - Philip Clarke, how are we going to pay for all of this in the long run? It just seems at the moment that Theresa May's magic money tree that we were told didn't exist, at the moment does exist. It's been reincarnated in the form of Rishi Sunak, the Chancellor of the Exchequer. This can't go on forever, though. There has to be ultimately a price to pay.

Philip - Yes, Chris. I mean, it really is initially by debt and I think governments have decided they are going to spend up and they have learnt lessons of the past that you've got to try to protect vulnerable people, such as people furloughed. But then I think there is going to have to be a conversation. And also then think about as our economy recovers, who will pay. And one of the interesting problems here is that, of course, this has mainly been about protecting older people, but it's of course younger people who have been most affected economically. So I think one's got to think about ways where you can actually have some of the payment back from that debt rather than falling on income and income of the younger people in society, have it actually be falling on older people. One's going to have to think about novel ways to collect taxes to pay for that debt in future, but also to put in place protections to stop the next pandemic. And that's another conversation we need to have

Chris - People thought or suggested that the NHS was underfunded before all this. Now the country has borrowed basically the amount of money it makes in a year and 50% of that again, we're estimating the cost by the time we get to about this time next year, it's going to be well north of half a trillion pounds. If the NHS was hard up to start with before all of this, and we've just borrowed that amount of money, it's not going to be a wash with money in a year's time is it?

Philip - I mean, I think there will be some, I suppose, difficult decisions for governments. I think they won't necessarily go back to the sort of austerity that people I think have viewed as having very big consequences for the health system and other parts of social care. But I do think it does give you an opportunity to also think about whether you can perhaps make the healthcare system more efficient. And of course, an obvious way is to be able to access GPs or healthcare professionals virtually to increase productivity. But yes, I think at the moment governments are borrowing and they are really leaving it to the next government and future governments to make decisions about how to pay for this in the long run.

Chris - Of course, one country that we keep returning to, people keep citing the Swedish model for how you can play out without potentially having to go down the route of a lockdown. We also heard from Jonas Ludvigsson, who's a clinical epidemiologist, he's also a paediatrician at the Karolinska Institute in Sweden. This is what he says.

Jonas - The Swedish strategy over the last eight months has been -  protect the vulnerable and risk groups. It's also been to keep society functioning, to slow the pandemic rather than to completely stop the spread of the virus. It's been to try to take other aspects of health into consideration so that despite the fact that we're in the midst of a storm of a pandemic, there are other aspects of health such as psychiatric health, cardiovascular health, cancer, et cetera, which we need to take into account...

Chris - Deepi, coming back to you, you must have been asked this an enormous number of times or had to consider this, what Sweden have done, which is to have less restrictions than we have had here in the UK. How does it compare? Is it a valid comparison or are we comparing apples with oranges and we really shouldn't do it?

Deepti - I think the scientific consensus on the Swedish strategy, including from the people who led it initially, is that it definitely wasn't the best strategy. And it's very clear that if you look at the death rates in Sweden, they're much higher than those of their Nordic counterparts - actually about 10 fold higher. So it's about 600 per million versus about 60 per million in many other Nordic countries. I think the worst part of it is that despite a more lax approach and trying to avoid lockdowns, they did not fare any better economically. In fact, there's very strong evidence now that how well a society does economically correlates very well with COVID-19 control. So Sweden has actually done as badly as Denmark, Norway and Finland, despite following a different strategy, but with about a 10 fold higher mortality rate.

Chris - And you don't think that the rest of Europe will catch up on the mortality stakes, because there is this concept of harvesting, bringing forward the inevitable, where someone's got to die of something let's face it, they could die of flu, they could die of Covid. Covid happened to claim them this time, they're not there for the flu to claim. Could it be therefore other countries will catch up and the numbers will equalise or do you think the countries like Sweden and the UK will always be outliers?

Deepti -  Well, I mean, the idea of catch-up has been promulgated for a very, very long time. And in seven months we haven't seen this happen. In fact, what we've seen is that the differences between countries that performed well and the ones that performed worse have become more and more stark over time. And that's what's likely to happen. In fact, we're hearing very much about the potential of successful vaccines being available quite soon. And it makes complete sense to try and control this pandemic as well as possible rather than letting it rip.