An Exit Strategy for COVID-19
In recent weeks the governments of many major European nations have been converging towards short-term social and economic lockdowns as a way of flattening the curve of COVID-19. As an emergency response, the policy is perfectly understandable, especially in light of what happened in Italy and Spain prior to their own now-belated lockdowns. I therefore take no issue with the lockdown measures as a reasonable short-term attempt to flatten the curve, and pre-empt the overburdening of healthcare systems. However, there has been a disturbing lack of clarity and even discussion about what is to be done next.
Below I sketch what I take to be the only reasonable chance we have of navigating our way out of the lockdown corner into which we have been backed. Before I begin, a couple of caveats:
- I am not not an epidemiologist, virologist, or medical professional. And so anything I say below should be taken with the appropriately sized pinch of salt. When speaking about the infection dynamics under different policy responses, I defer to the expertise of those who have published the Imperial College London reports.
- In the interests of full disclosure, my academic background is in Political Theory, in which I hold a PhD from University College Dublin. I don’t suppose this makes me especially qualified to comment on pandemic dynamics; however, the crisis does obviously have a political and economic dimension, in which I have some training. I try as far as possible to “stay in my lane”. However, with the exit strategy I propose, I am admittedly going out on a limb. That’s precisely why I’m publishing this: I desperately want feedback from those with greater expertise than me on viral/pandemic dynamics. Despite my lack of medical background, I don’t think that necessarily disqualifies me (or anyone else) from coming up with a viable policy mix beyond the lockdown phase. It may of course make it less likely that I will happen upon the answer, but I don’t think it mandates silence. This is an unprecedented scenario in the modern world, and we appear to be stuck with respect to phase 2. An intellectual policy of “all proposals welcome” is, I would suggest, the prudent one.
With the obligatory hedging dispensed with, let’s get into it. In the aforementioned Imperial College paper, the authors conclude that a lockdown approach is likely to be the most effective at flattening the curve. The problem, of course, is that this pertains to a relatively short-term time horizon — perhaps a few months at best:
“[M]ore intensive interventions could interrupt transmission and reduce case numbers to low levels. However, once these interventions are relaxed, case numbers are predicted to rise. This gives rise to lower case numbers, but the risk of a later epidemic in the winter months unless the interventions can be sustained.”
Herein lies the crux of the problem we’re facing. Assuming a successful curve flattening followed by either a total or piecemeal lifting of the lockdown, we are faced with the near-inevitable prospect of second and third waves of the epidemic in each country. The notion that no other infected person or contamination source will re-enter each society in the coming months is beyond wishful thinking. And so we may take for granted that the second wave will come, and more likely sooner rather than later given the observed virulence of the COVID-19 virus.
I interpret this essentially to be a disqualification of the following two candidates for a phase 2 policy: (i) lift the lockdown completely after, say, 1 month; or (ii) gradually lift the lockdown by, e.g., first re-opening schools, then re-opening restaurants/hotels etc, then eventually allowing everyone to return to work. In both cases, the second wave looms imminently. It may occur more rapidly in (i) than in (ii), but there is nothing in option (ii) that prevents the second wave. In either case, we are faced with the gloomy prospect of having to retreat to total lockdown as soon as the second wave hits. Even if both (i) and (ii) are accompanied by enduring personal hygiene and social distancing observance, from what I understand of the Imperial College report, the second wave will occur before too long — albeit at a moderately reduced rate of spread.
I take this also to constitute a disqualification of the present policy simply being extended indefinitely — namely, either enduring or cyclical total lockdowns until a vaccine is found. I take anyone who seriously endorses such an approach to not be a serious party to the discussion. Indefinite lockdown for 18 months or 2 years would likely have such devastating humanitarian impacts globally (think of all the knock-on effects of a global economic depression from a healthcare point of view, lower resources available for health systems, scarcity of medicines, rampant poverty, etc etc) that the cure would indeed end up being worse than the disease. Of course the precise magnitude of such effects is difficult to quantify, but the authors of the Imperial College report admit that they are certainly likely to be significant:
“It is important to note that we do not quantify the wider societal and economic impact of such intensive suppression approaches; these are likely to be substantial. Nor do we quantify the potentially different societal and economic impact of mitigation strategies.”)
If these were the only three policy options on the table in the absence of a vaccine, then we would be facing a very dire situation indeed. And from the public discourse in recent weeks, one could be excused for thinking that indeed they are the only options. I find it baffling that one obvious alternative has scarcely been mentioned — although in the context of the UK and Ireland, I have a suspicion as to why it has been mooted, more on which towards the end of this piece. Now to the alternative.
The Exit Strategy — Enforced Shielding
The only viable exit strategy that I can see I will call “enforced shielding”. The policy is as follows:
Following the initial complete lockdown phase of, say, 4 weeks, extend a legal lockdown on all those over the age of 70 (the age cut-off is bound to be contentious, and so I remain fairly tentative on this point) and those with pre-existing chronic health conditions for a period of, say, 8 more weeks. Ensure that all those who fall into that category are robustly provided for by the government in terms of food deliveries and provision of medicines, medical attention and other supplies, in accordance with stringent hygiene and social distancing standards. Allow the remainder of the population to return to work as normal and carry on with their regular economic activities in all sectors, while observing hygiene best practices and social distancing guidelines wherever possible. This would allow the economy to be maintained with a comparably marginal depressive effect from the initial lockdown. In that 2 month period, the government can rapidly ramp up the healthcare system’s intensive care capacity and respirator supply (supported by recovering public finances with renewed tax revenue). Meanwhile, many of those in the less-vulnerable population are likely to become infected. Of course, *some* will still require hospitalisation, but a much, much lower rate than would have been the case had the vulnerable groups not been systematically shielded. In that way, the curve flattening could be extended, albeit to a somewhat lesser degree. Continue with extensive testing as far as is practical, and perform tracing to ensure no vulnerable people have been linked to confirmed cases among the less-vulnerable population. Then, after the 8 week period, begin to lift the restrictions on those from the vulnerable groups. By this time, a large number of the less-vulnerable will already have been infected and developed at least medium-term immunity. The vulnerable will then be less likely to become infected by any random member of society as a significant proportion will be immune and no longer capable of carrying and infecting others. Those vulnerable who nevertheless do get severely or critically ill from that point on can now be comfortably accommodated by the recently, aggressively expanded healthcare system.
What I advocate above is not far from scenario C in the Imperial College paper: “Mitigation including enhanced social distancing of the elderly — as (B) but with individuals aged 70 years old and above reducing their social contact rates by 60%.” However, crucially, I include those with pre-existing health conditions in the shielded group, and a legal lockdown of that group with government provision of supplies/medicines, rather than merely a voluntary, hoped-for “60% reduction in social contact rates” by those vulnerable groups.
The advantages of this approach are: 1) it still helps to flatten the curve in the short-term to medium-term; 2) it prioritises protection of the most vulnerable groups; 3) it minimises the threat of second and third waves of infection amongst the at-risk groups in the medium-to-long term; 4) it avoids a complete decimation of the economy and potential years-long depression, with all of the potentially negative psychological and health effects that *that* entails.
Objections
O1. “Are you suggesting that we should just ignore the current lockdowns and do what we want? Isn’t that incredibly irresponsible and risky?”
Response: I’m absolutely not suggesting we should ignore the current lockdowns or not observe social distancing/strict personal hygiene. For as long as we’re going for total, population-wide lockdowns, we should ALL certainly be complying with government guidelines and minimsing social contact, unnecessary travel and observing stringent hygiene standards. I don’t think the total lockdown approach will be *completely* ineffective in certain respects (e.g. flattening the curve in the short-term), and I think there’s a non-negligible chance it could eliminate the virus from the relevant society completely. But it still does strike me as highly improbable. And you then have to contend with people bringing the virus back in from the outside. I suspect most are unwilling to close all borders all over the world indefinitely.
O2: “Aren’t you just being really selfish, and it’s just that *you* as a younger person without pre-existing health conditions don’t want to have to make sacrifices and want the vulnerable to have to bear the burden?”
Response: Not at all. For the record, being at home for me personally is far from a major sacrifice as I can work from home in any case. Quite the opposite in fact! And in any case, in the current lockdown scenario, the vulnerable are still being required to confine themselves (and that lockdown would likely have to be reintroduced when the second and third waves kick in).
O3: “Surely what you’re proposing is hugely impractical? How can we ensure the vulnerable groups are locked down and adequately looked after and don’t interact with those potentially carrying the virus?”
Response: The exact same objection applies to the total lockdown approach, except that I would suggest that the total lockdown approach is even *harder* to enforce consistently. And so that is more of an objection to the prevailing approaches in Europe than to what I’m advocating. Of course it would be challenging, and in all likelihood not perfectly observed/enforced. But if perfection is your standard, all approaches in the real world are disqualified immediately.
O4: “Aren’t you just endorsing ‘herd immunity’? Isn’t that just pseudo-scientific bunk?”
Response: I don’t really care what one calls it. I’m only concerned with the logic of the position. Rhetoric doesn’t interest me, and I understand why political opponents of Boris Johnson (for the record, I count myself amongst them) quickly homed in on that phrase, because it sounded cartoonish and pseudoscientific. But the idea of herd immunity has longstanding scientific merit. I’m aware that we don’t have definitive evidence that once you get infected with the COVID-19 virus and recover, you are permanently immune. But what I’m endorsing doesn’t require 100% immunity indefinitely. Even medium-term immunity would be sufficient. And that’s typically what you get with other coronaviruses, so there’s no reason to think at this point that COVID-19 is much different. Unfortunately for those who are now (unreasonably) rhetorically allergic to the phrase “herd immunity” because it has become associated with “BoJo” and (wrongly) equated with a “do nothing” approach, overcoming this virus and pre-empting/mitigating second and third waves *does* seem to necessitate some element of a herd immunity dynamic taking hold amongst the less-vulnerable population— until we have a viable vaccine ready for mass production (i.e. probably 18 months in a best case scenario).
