What is the long-term exit strategy?
Public health expert Dr Peter English on how we get back to something approaching normality
As I write, the country is in lockdown. The harms of lockdown can’t be avoided. Quite apart from the direct effects on individuals, companies will fail; businesses will go under – the whole of the previously thriving hospitality and entertainment sectors have gone into hibernation. Health is closely linked to wealth – and to inequalities in society. Will the economic harms outweigh the benefits of lockdown, or will it all be worth it?
So we are all desperate to return to normal. But when will we do so? What will be the steps in getting there?
You’ll see a lot about this over the next days and weeks. BMA’s Public Health Medicine Committee has been working with others in the BMA on this; and the Prime Minister has told us that they’ll announce a plan ‘next week’.
The first stage will be getting on top of transmission. There are two factors here: the transmission rate; analogous to the speed you’re travelling at; and the rate this is changing. If the average case infects exactly one other person (R=1), the number of cases – the speed of travel - won’t change. If there are more cases than we can deal with, as there are now, we’ll struggle; we’re still driving at 120mph. We have to put our foot on the brakes – to bring R down well below 1. The lower we can get it, the more quickly the number of cases will fall to a manageable number. If we lift restrictions too soon we’ll be pressing on the accelerator pedal instead, and case numbers will continue to climb exponentially.
So we need to both get the speed – the case numbers – down to a manageable level, AND ensure that we don’t allow the disease to accelerate by allowing R to rise above 1 again.
Once we’re down to, say, <100 cases per week, we might cautiously take our foot off the brake. You catch Covid-19 by breathing in expired droplets, and by touching contaminated surfaces – we’ll have to keep measures in place to control transmission; but we could allow people out for more exercise. Allow people to go to work more – but probably not to sit in crowded entertainments, pubs or restaurants.
Over time, we will work out what the risks of different activities are, and relax restrictions on the least risky ones.
Transmission risk is far lower outdoors, where air circulation is greater; the level of proximity that’s a risk is much lower, so I’m particularly looking forward to abandoning the current, absurd restrictions on outdoor activities. There’s no harm (apart from dermatologically!) in sunbathing or enjoying the outdoors, if you can do so without getting too close to others. The complaints also usually focus on poor people without their own outdoor spaces.
We will also find ways to mitigate risks, such as facemasks. People are infectious for up to 48 hours before developing symptoms. Wearing a mask while infectious reduces onward transmission. The UK is unlikely to remain an outlier. The reason for not mandating facemasks – presented as ‘following the science’ – is, in reality, based on concerns about supplies, not science.
Any relaxation of lock down will require the transmission speed – the number of new cases per week – to have slowed down, so that we can follow up each case, and all of their contacts, and advise the contacts to quarantine until we can be certain they aren’t incubating the disease (and thus likely to pass it on to others).
Will antiviral treatments have a role? There’s a lot still to learn. Most patients never develop severe symptoms, but in those that do, it happens at a time when most patients no longer have viable (infectious) virus particles in their respiratory secretions. (You may well ask how dangerous it is to work on acute Covid-19 wards and ICUs – nobody is certain. It is possible that most of their patients are no longer infectious.) So it’s not clear what role they’ll have in treating patients once they develop complications.
In other diseases, antivirals are at their most effective if given as early as possible – ideally before the onset of symptoms. Antivirals work in care homes, not because they treat the patients who’ve got flu; but because they hugely reduce transmission (they reduce viral load and duration of shedding); and given ‘prophylactically’ they treat patients before they develop symptoms.
Early studies seem to indicate that antivirals such as Remdesivir might act in a similar way; it’s possible that prescribing them to close contacts might reduce the risk of their being seriously ill, and of passing the infection on to others.
But the long-term goal is a vaccine. We won’t get such a vaccine straight away. There are literally hundreds of vaccine candidates being developed at present, using a range of approaches. It’s hard to imagine the testing for safety, efficacy and the manufacturing and distribution processes being in place by 2022 (although I wouldn’t bet my house against it).
If we do it right, we’ll come out of this crisis with a kinder, more efficient, and more effective primary care
With luck, it will provide good, long-term, protective immunity; a level of immunity which not only protects the recipient, but also prevents them from being infected and infecting others.
But the truth is we won’t know whether the virus will mutate and change, under evolutionary pressure from our vaccine-provided immunity, or whether vaccines will be able to target immutable proteins without which the virus will never be able to function, however much it mutates.
And we don’t know yet how long the immunity from vaccination will last: will it be like measles immunity, which usually protects for a lifetime? Or like pertussis immunity, which lasts a decade if you’re lucky? (Although if you do get the disease after that, you generally get a very mild, ‘attenuated’ form of the disease).
But perhaps most interesting is what society will look like once all this is over. Will Covid-19 be a wake-up call, that will allow a fairer, higher-tax, higher state funding society, in which we don’t humiliate and punish people who can’t find work, and in which the state looks after the old, sick and disabled properly? Or will the xenophobic nationalists be further emboldened, with authoritarian populists taking over everywhere, increasing the likelihood of world war three?
And the health service. Primary care has been forced to adopt remote consultation by the need to avoid transmitting Covid-19. If we do it right, we’ll carefully evaluate what worked, what didn’t, and come out of this crisis with a kinder, more efficient, and more effective primary care; and no doubt there will be similar seismic changes both in acute medicine and in the care sector.
We will have to fight to ensure that the changes are the right ones. It’s down to us to ensure the politicians lead us to a more-or-less utopian future, rather than to a dystopian one.
Dr Peter English is chair of the BMA Public Health Committee and is a former GP. He is writing in a personal capacity