Why has this happened? We can look at individual events, such as when lockdown started. But the truth is more profound. England has been following a different strategy from all of the rest of Europe, if not the world.
The roots of the strategy are in the approach to flu. So let’s start there.
ENGLAND’S FLU STRATEGY
COVID-19 is not flu. As discussed here it is much more serious. Firstly nastier initial symptoms, which can result in death. Then severe ongoing symptoms now known as LongCOVID, which can apply to people old and young, including children with of MIS-C, Multisystem Inflammatory Syndrome in Children, . LongCOVID is looking like it will effect far more than die, and therefore is becoming a bigger problem.
But it's worth understanding how the UK has approached flu.
But there is one other aspect. The worry each winter, when flu is more common, is that the NHS will be overrun. Stopping that is the number one objective. Provided that is the case, the incidence of flu is tolerated.
Let’s call this the “Flu Strategy”, which is to avoid overrunning the NHS.
Ring a bell? Because that is basically the same strategy that is being followed for COVID-19.
Everything is about avoiding overrunning the NHS. The 5 tests for easing lockdown had “Avoid a second wave” changed to ”Avoid a second wave that would overrun the NHS” Important, but should that be the number one objective?
The other phrase that is relevant to the Flu Strategy is “running hot”. A national infection rates not as low as it could be, in theory to allow ordinary life to take place. But the lack of confidence now means this isn’t happening in practice. The deaths and LongCOVID without the benefits,
Other countries take different approaches. Different strategies. Let's explore them.
THE DIFFERENCES FOR COVID-19
- It is a far more serious disease, including not only death but LongCOVID, and much longer infection periods. The basic COVID-19 affects the over 50s more severely than younger folk. But LongCOVID applies to young and old, including children
- No natural immunity in the population, nor a vaccine yet. So virtually every person young and old is susceptible to COVID-19
Clearly a different strategy is needed for COVID-19 compared to flu.
What we’ve seen is that it is possible to eliminate COVID-19 in a territory, but it can very quickly come back if people relax. This is especially true for territories that have a lot of people travelling in from abroad.
The other key aspect is that COVID-19 is so contagious, it will be many years if ever before it is eliminated from the world entirely. So for strategy purposes we should assume COVID-19 (or other similar coronaviruses ) will be a threat for the foreseeable future.
The different types of strategy are given specific names, commonly used in the global scientific community:
Cases and small outbreaks may still occur once a disease is eliminated, imported through people arriving from outside the territory. Those people will be visitors and citizens returning home. But by keeping alert. watching out for such spikes and dealing with them effectively, they don’t lead to sustained community transmission.
The Independent SAGE call this strategy “ZeroCOVID” and “TowardsZero” Though that is not necessarily the best approach. This is discussed below.
- Social distancing
- Hand washing and other hygiene techniques
- Mask wearing
- Lockdowns, of varying severity, where people need to stay at home, and some businesses are forced to close
- Bans on large gatherings
- Test trace and isolate
- Families being kept apart, and general loneliness
- Financial losses for businesses, with the risk of unemployment, and reduction in opportunities for the self-employed
- Loss of personal income leads to major family problems
- Mental health problems
- Cost of the measures themselves, especially test/trace/isolate
- Reduction of tax receipts for government, coupled with extra spend on support and unemployment, putting a big strain on national borrowing and associated GDP ratios
However rampant infection suffers from much of the same problems, in addition to the deaths and LongCOVID. So suppression is a matter of striking a balance between the level of infection and the pain of the suppression techniques needed to drive infections any lower. “Elimination” means striking that balance right down at a zero level of infection. That may be too tough, and unnecessary
So just like medications, suppression techniques need to be used selectively
What is important to a Suppression Strategy is that nobody wants their health service overrun, like we saw in Italy, if it can possibly be avoided.
There is also “Herd Immunity”. This is the idea that once at least 60% of a community have had the disease, the disease will have much more difficulty finding an uninfected person, and the disease will tend to die out. Lower rates will slow spread of the disease.
As shown here, 60% would take many years in any territory. We also don’t know if people gain any natural immunity from having the disease, though there are now some promising signs. As it is a new disease, we certainly don’t know how long any immunity lasts. In the absence of a vaccine, no country is following a pure Herd Immunity strategy.
NEW ZEALAND
But primarily they took advantage of their island status, with a relatively low level of international travel, to avoid the disease taking hold and then drive it out of the country completely.
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To do this, they have had to institute a draconian regime for immigration, including their own returning citizens.
So far so good, in that they have been able to tackle every spike arising. though the first cases of COVID-19 were two Brits over for a family funeral.
That Elimination strategy has allowed New Zealand to completely lift restrictions and get life back to normal. Wouldn’t that be nice?
Taiwan has done likewise.
Taiwan has done likewise.
It’s tough work though, wth major restrictions on travel freedom. You have to wonder whether that is sustainable for the long term.
Update 11/8/20: Indeed today I hear of 'trouble at mill' in Auckland, New Zealand's largest city. The country has been free of any COVID-19 cases for 102 days, well over three months. So keen is the government to maintain their #ZeroCOVID status that for just 4 cases in one family, the whole city will be in strict lockdown from tomorrow, Wednesday 12 August for three days. They still don't know the source, The PM. Jacinda Ardern, has advised people to "act as if you have COVID, and as if the people around you have COVID".
Indeed that is how we all ought to live. But lockdown a whole city? Schools closed, everything? Even for just a few days? Though that's likely not to be sufficient if others have already been infected. Surely this sort of approach isn't sustainable every time a few cases arise? True #ZeroCOVID, with elimination in a territory, is just not feasible long term.
We have to find a way to live with the virus at very low levels.
Update 11/8/20: Indeed today I hear of 'trouble at mill' in Auckland, New Zealand's largest city. The country has been free of any COVID-19 cases for 102 days, well over three months. So keen is the government to maintain their #ZeroCOVID status that for just 4 cases in one family, the whole city will be in strict lockdown from tomorrow, Wednesday 12 August for three days. They still don't know the source, The PM. Jacinda Ardern, has advised people to "act as if you have COVID, and as if the people around you have COVID".
Indeed that is how we all ought to live. But lockdown a whole city? Schools closed, everything? Even for just a few days? Though that's likely not to be sufficient if others have already been infected. Surely this sort of approach isn't sustainable every time a few cases arise? True #ZeroCOVID, with elimination in a territory, is just not feasible long term.
We have to find a way to live with the virus at very low levels.
IRELAND, SCOTLAND AND WALES
Ireland has followed a similar Eradication Strategy, and been very successful in getting infections down to a very low level. Northern Ireland has joined them in effectively treating the island of Ireland as a ‘territory’.
Scotland isn’t far behind, with daily deaths often zero, by keeping lockdown restrictions longer than England. It’s amusing that the Scottish National Party government, who advocate independence from England, has threatened to close the border with England. This is due to the much higher level of infection in England threatening Scotland’s success in eliminating COVID-19.
Wales are also following suit, with infection levels and deaths dropping.
Within the United Kingdom, England is the exception, following a very different strategy, which we will look at below.
CONTINENTAL EUROPE AND THE FAR EAST
Countries such as Spain instituted a very strict lockdown regime, with people only being allowed out of their homes about once a week for food.
Not surprisingly once restriction were mainly lifted, the relief has meant sensible precautions have not been followed, and cases have started to rise again. Quite severely in Spain.
This is the pattern, to a greater or lesser extent, in all the countries adopting an Elimination Strategy. This includes Australia, Japan, South Korea, and all the European countries such as Germnay..
These countries have also found:
- A land border is difficult to control and will let new infections in
- Local surges, such as in meat processing factories, as happened here in Germany
Nonetheless an Elimination Strategy is letting most of these countries substantially release lockdown restrictions, albeit with typically a stronger emphasis on wearing masks than in the UK.
UNITED STATES OF AMERICA, INDIA, AFRICA AND SOUTH AMERICA
The rest of the world is adopting a range of strategies, sometimes because of lack of funds.
Mexico and Brazil are now sadly soaring up the international death charts. India is struggling to control the virus, and that is a problem in much of the under-developed world.
I’m struggling to coin a term for the US approach, other than to call it misguided.
SWEDEN
Which brings us to Sweden. It is the only country in Europe, possibly the world, to deliberately avoid a formal lockdown. They have kept their schools open, and most businesses open. Just a few restrictions, such as banning larger events over 50 people.
They have not insisted that people self-isolate, haven't done a lot of testing, and have recommended against people wearing masks.
As the opposite of most other countries Sweden has become an ideal 'control' against which the effectiveness
of other countries' strategies can be judged.
You might expect me to rubbish their approach. But they may have struck it right.
The core reason is that they have taken a long-term balanced view of all the objectives, be they health, education, financial and life in general. They have educated their citizens and left it to them to do a voluntary lockdown. In the expectation that would be more durable over the months and years that COVID-19 will be around. Not a Herd Immunity strategy as such, but Suppression.
When COVID-19 first appeared, there was no knowledge of LongCOVID, so in hindsight they may have approached their strategy somewhat differently. There was also had no knowledge as to whether there would be any natural immunity, so no immunity was assumed, such as that any immunity would be a bonus..They now believe that is happening.
What they realised was that COVID-19 was so infectious it would be around for the long term. None of this ”it will be over in 2 weeks” nonsense, that gave people false hope in the UK and elsewhere.
They realised that a long term strategy was needed. The relationship between the public and the state is more one of trust than in many other countries. Which gave them the opportunity to explain COVID-19 to the public and get them to voluntarily lock down. This has meant, for example, that travel within Sweden reduced as much as in neighbouring countries. There is noticeably less activity than normal in cities such as the capital Stockholm.
Here's a cultural comparison of Sweden to the UK that underlies Sweden's strategy.
Here's a cultural comparison of Sweden to the UK that underlies Sweden's strategy.
The economy has taken as much a hammering as neighbouring countries, partially because they are as dependent on trade with foreign countries which are struggling. But there are now strong signs of recovery, according to a recent Financial Times article "Swedish companies reap benefits of country’s Covid-19 approach". What's good for businesses is good for jobs and good for the Swedish Exchequer.
Initially deaths were much higher than neighbouring countries. Much of that was due to care homes, and they recognise with hindsight that they could have done better in shileding people there. They also believe that cases were higher than elsewhere because the Stockholm area's spring break corresponded with the initial surges in Italy and Spain. So a lot of Swedes went on holiday and brought the illness back to Sweden at the same time.
Nonetheless they have avoided their health service being overrun, and are not faced with the traumas of releasing a lockdown. The Swedish people are fundamentally controlling that.
Deaths are now down to very low levels, as are new infections. We might expect Sweden to now fall down the European league table as other countries such as Spain overtake them, having failed to control their people after their strict lockdowns.
Sweden is also not recommending the use of masks. Their strategy has been based primarily on social distancing, and the concern is that masks will give people a false sense of security. Most masks provide little if any protection for the wearer, and social distancing might lapse.
Given that winter is expected to favour the virus, with people being more indoors, the time to assess Sweden’s strategy will be primarily in March 2021 nd March 2022, a year and two years after the disease hit Europe. So far Sweden’s progress relative to other countries is much as I expected, certainly now Elimination countries such as Spain are now having so many problems.
When assessing the results of Sweden's strategy, it is not just about deaths and LongCOVID. We need to bear in mind that they have largely avoided the nasty side-effects of a formal lockdown. Schools staying open and families deciding for themselves whether to self-isolate or meet each other.
My expectation after two years, and possibly one year, is that Sweden will be in the best three in Europe for deaths, and clearly top overall when all the objectives for health, education, financial and life in general are considered. I'll bet a fiver on it. Though they may have to adopt more formal measures if their health service is threatened with being overrun this winter.
Sweden’s border with Finland had been closed from Finland’s perspective, but has now been opened on the same basis as France, Spain and others given the reduction in Sweden’s infection rate.
I had expected countries like Spain to decide to ban British holidaymakers, but clearly they feel the economic hit would be too high. Ironic then that Britain should make anyone returning from Spain to have to self-isolate (quarantine) for two weeks. That is because of surges in some mainland areas. The restriction also applies to the Balearic and other islands that have had very low rates of infection. Deeply unfair and inappropriate.
But it does show is that there is an advantage to having a very low rate of infection on the international stage. That applies as much for the benefit of business ttravellers as it does to holidaymakers.
SO WHAT IS THE RIGHT STRATEGY FOR ENGLAND?
Initial Strategy
It was then a matter of keeping a lockdown as a last resort . I was hoping for a light lockdown. But realised on Friday 13 March, auspiciously, that a reasonably strict lockdown would be essential.
The government for England did some initial anti-transmission
measures in teh following week, such as closing schools, and then succumbed to ordering a full lockdown from 23 March. Arguably at least a week too late, and causing thousands of avoidable deaths. But I can understand their reticence, given the dreadful 'side effects’ of lockdown, and am grateful that we were allowed out of our homes at least once a day.
The real issue now, though, is what is England’s ongoing strategy? Get it wrong, and it can mean many more deaths and LongCOVID sufferers than have occurred so far. For little or no benefit to life and the economy.
It is clear that the current strategy is to allow the level of
infections to stay at a low level, at Alert Level 3, rather than “very
low” at level 2. But why?
Talk is always about “Saving the NHS”. Originally one of the tests for easing lockdown was to “avoid a second wave”. This was changed quietly to “avoid a second wave that overwhelms the NHS.” A willingness to let infections rise, provided the NHS isn't at risk. That's a Flu Strategy, as explained above, and effectively ignores LongCOVID.
It was very enlightening to watch Professor Chris Whitty on Friday 31 Julytalking alongside PM Johnson as he announced that the planned easings on 1 August would not be going ahead. This was, alongside a light lockdown across much of the north of England, and a clear sign that a national lockdown is on the cards.
Prof Whitty said “we have probably reached near the limit, or the limits, of what we can do in terms of opening up society.” And the “idea that we can open up everything and keep the virus under control" is wrong.
It is therefore clear that Prof Whitty accepts the current level of infections. Whether that is of his own volition or because the government has set it as an objective is unclear. But every time Whitty says “as long as R doesn’t go over 1.0”, where 1.0 maintains the current rate of infection, he is effectively saying the current rate on infection is acceptable I wince every time.
Whether Prof Whitty’s joint chair of SAGE, Sir Patrick Vallance, agrees is a moot point as he was unusually absent from Friday’s press conference. There may be a perfectly good explanation for his absence, but it was striking.
It might be good to follow Sweden's lead, and make measures primarily voluntary. But England doesn't have the right kind of societal foundation to do that. If anything, any trust in the government has been
lost. Nonetheless we can learn from Sweden that educating the public can have
significant benefits.
Which means that England should follow Ireland and Scotland with a ZeroCOVID or #Nearzero strategy.
ZeroCOVID or NearZero
Most vociferous in this appraoch is the Independent SAGE group of academics and former SAGE members which is advocating a “ZeroCOVID” Elimination policy. This is effectively extending the Irish policy to the whole of the British Isles.
A major concern as summer turns into autumn and then into winter is that COVID-19 is more likely to spread when people are more indoors. It appears that viruses on microdroplets can stay active in still air for some 3-4 hours, which is a real problem unless there is good ventilation. Lifts for example.
The lower the infection rate by the end of August, the better chance we have to control any second wave over the winter. Especially as the recent rise in cases suggests the second wave has effectively already started, and needs to be nipped in the bud.
A priority is to get schools back in September, and higher education shortly afterwards. This again will be much easier if the new infection rate is down to a very low level. Parents would be much more likely to willingly comply in sending their children to school.
A very low infection rate will also give people the confidence to go out, and therefore spend money. It is therefore better for the economy and the Treasury for a very low level of infection to be achieved.
Plus of course a lower level of infection means fewer deaths and less LongCOVID, adn many otehr benefits.
So I tend to agree that a ZeroCOVID Elimination strategy is far preferable to England’s current Level 3 strategy. But I hesitate to say Zero. #NearZero is perhaps a more practical ambition. Providing virtually all the benefits of Zero, but more achievable.
Ireland is well on its way to Zero, and has already reached NearZero. Independent SAGE are suggesting England and the rest of the British Isles can achieve Zero by improving the Test Trac/Isolate system.
As discussed in the following blogpost, that is more theory than practicable. Certainly not achievable to have the desired reduction in infection rate by the end of August.
The only reliable alternative in that timescale is a second, short lockdown. An investment we cannot afford not to make. As explained here, three weeks is all that’s needed to get new infections down to around five sixths of what it is currently, or better, depending on how the lockdown is conducted. That would make a massive difference.
The sooner the better, before infection rates around the country increase too far for a short lockdown to be sufficient.
But in any case, is a short lockdown really sufficient?
There is no point getting infections down, only for them to rise substantially again, as is happening in Spain, Australia and elsewhere.
Here Sweden’s experience is vital. The British public need to keep good practice going for the foreseeable future, That means the British public need to understand not just what, but why. The whys and wherefores about COVID-19 clearly explained, as I have hopefully achieved in this blog, but in a more powerful way appropriate to the many different ethnic communities.
I’m amazed by the lack of basic understanding amongst people in managerial positions who I meet. Clearly “common sense” is not enough for something like COVID-19 which is outside everyone’s previous experience. Getting the message across to all parts of society, including those who do not have English as their first language, is a challenge for professional public communicators. That needs to be far better than being done currently.
Not only does the communications need to improve dramatically, there ought to be people out in the community advising, encouraging, and if necessary chiding. Aren’t there contact tracers fiddling their thumbs? They need to become modern-day air raid wardens.
There are a variety of possible strategies, given we are going to have to live with COVID-19 somewhere in the world for the foreseeable future.
The best strategy for England is to adopt the same ZeroCOVID (or NearZero) strategy as Ireland and most of continental Europe.
That means getting new daily infections down to Near Zero by the end of August, before the schools go back, if at all possible.
That timescale requires a reliable way of getting infection rates around the country right down. That would need to be a reasonably hard lockdown for three to four weeks. This is preferably leaving outdoor places like pubs and cafes open, given that there is far less transmission outdoors. Perhaps allow holiday accommodation to stay open, but with people having to treat it as their base for lockdown
Extra financial support would be needed for businesses and people impacted, but this would be a small investment compared to the cost of leaving infection rates too high.
We then need to keep infection rates down, better than other countries. That requires an education campaign for the British public, so that them following good transmission measures is fundamentally voluntary, and far better than achieved so far. This would preferably be supported by local personnel acting as the modern-day equivalent of air raid wardens – out on the streets advising, encouraging and if necessary chiding.
That would make it easiest to reopen schools, reopen the economy, and be best prepared for the winter. Plus of course minimising deaths and people suffering from LongCOVID.
Surely a NearZero strategy and a short, sharp lockdown in August is what we must do? Short pain for much gain.
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