Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.
It’s just over a month since I wrote of my experiences on the Covid-19 frontline and my hope that we would all work together to defeat this virus and its harmful consequences.
But as we begin lifting lockdown restrictions, I am worried that our recovery is being threatened by our divisions into “pro- and anti-lockdown” camps – or as recently described – “the trusting”, “the dissenting” and “the frustrated.” The debate has become ever more polarised with misleading claims and counterclaims, based on the selective use of evidence and statistics being used by all sides.
Although there was broad agreement among scientists and politicians on the need for bringing in lockdown, along with wide support from the general public, that consensus has broken down when it comes to lifting restrictions. Nowhere has this been more apparent than in relation to schools re-opening with each side even having its own group of SAGE advisors.
With scientists openly disagreeing about the risks of lifting restrictions, this leaves the public either confused – or simply choosing which experts to follow – leading to fear and complacency both of which are negatively affecting people’s behaviour.
Because even as the Government lifts some restrictions, half the population are still very worried about Covid-19 and are not going to return to school / work / shops / hospital, etc. until they are convinced it is safe. (Only 25 per cent of eligible children returned to school last week). Generally, they vastly overestimate their risks both of catching and dying from Coronavirus.
I completely understand those fears – months of seeing people dying on the news and knowing someone who has been ill will always have more impact than statistics – and tragically, for tens of thousands of people, their worst fears have been realised as they have lost loved ones. Therefore, more attention needs to be given to explaining to this group just how low their / their children’s risk is and highlighting the evidence from other countries where schools and economies are safely re-opening.
On the other hand, roughly a third of people are becoming complacent about the risks and less compliant with guidance on social distancing, washing hands, self-isolating, etc. This group must be reminded that following this guidance is critical to reducing transmission of the virus and the risk of a second peak (which has actually happened in Iran and some American states) and that, although it may not help them directly, it is essential to protect those who really are at much higher risk.
Therefore, the first action required is to improve the public-health messaging so as to convince both groups. This will require us to trust the public and to be honest about the risks and benefits – and must be delivered by the right messenger. Doctors are used to doing this and the most trusted by both sides and so should take on this responsibility with the lead being taken by the Chief Medical Officer.
The second is to bring the scientists together and agree a way forward. They actually agree on most things – all accept that the lockdown measures are doing significant health harm (and should be lifted when infection rates are “low” – but don’t agree how low that is) and that lifting restrictions has potential risks – what is unresolved is where the balance of harm lies.
The major point of disagreement is on the risk a second spike. Having personally dealt with the death & suffering of Covid-19 patients in the first peak, the last thing I want is a second peak, but it is hard to see how this would overwhelm the NHS (the fifth test) given the current level of infection (one in 1000, down > 90 per cent) & R (around one); the fact that most people are not going to stop complying with the guidance and the gradual easing of restrictions which would us enough time for targeted interventions (i.e. local lockdowns) to prevent that.
Based on the available evidence, it is clear to me that the harms of lockdown (particularly school closures) are exceeding the benefits but the conflicting scientific advice puts the Government in a difficult position and I therefore support the decision to gradually ease the lockdown while closely monitoring the impact of those changes.
We must also maximise the number of cases and contacts being tested, traced and isolated to minimise the risk of a second spike. Ideally this should be fully operational now but we cannot let the perfect be the enemy of the good – and delaying easing can only be justified if it is clear that this will cause more benefit than harm.
Indeed, the critical question is not whether there will be a second spike but whether the harm caused by that is greater than that caused by continuing restrictions. i.e. “Does continuing lockdown have greater health costs than benefits?”
From the SAGE minutes, there appears to have been excessive concentration on one metric (mortality from Covid-19) when of course the objective must be to save the most lives from all causes and equal consideration must be given to those who will die now from Covid-19 versus both now and later as a result of lockdown and its consequences.
There has also been extensive modelling on the effect of different measures on Covid-19 (which of course was necessary and appropriate) but much less on other diseases, overall mortality or the economic, social or psychological consequences of lockdown. Neither the Covid-19 recovery plan nor SAGE’s minutes indicate that a formal “health cost-benefit analysis” has been done.
The only analysis I have seen, done by the LSE, used the number of “Wellbeing-Adjusted Life Years (WELLBYs)” as a metric (similar to QALYs – Quality-Adjusted Life Year – which the NHS uses to decide which treatments should be funded) and concluded that lifting the lockdown fully on June 1 would have an overall net health-benefit (albeit by only one WELLBY) whereas on May 1 it was clearly harmful, and on July 1 is clearly beneficial.
The Government should therefore immediately convene both groups of scientists and – along with economists – conduct a comprehensive cost-benefit analysis (based on all the latest data) on the re-opening of schools, the economy, society, etc. – and come to a consensus. This would then form the basis of a plan for politicians of all sides and the public to follow and allow the debate to move on from the false choice of, “Lives vs. livelihoods” or, “The economy vs. public health.”
I accept that this may be optimistic but the stakes are too high not to try – continuing division is damaging our current and future health & education, and costing lives and livelihoods. And the gap is not actually as wide as it appears – both sides share the same objectives and means, differing really only on timing.
All agree that re-opening schools is critical for our physical, mental and economic health and that children should return as soon as “it is safe.” The point of difference was when that would happen – iSAGE recommended schools started on June 15th when they projected that the risk would be acceptable – but figures released by the ONS show that the risk fell to that level by May 30.
Finally, of course we are not primarily “pro- or anti- lockdowners” – we are all “pro-protecting lives and livelihoods” and wanting to recover from this crisis as quickly as possible. And so, we must put aside our differences, compromise and come together in the national interest. “A house divided against itself cannot stand.”