The decision to impose a second lockdown in England is polarising people to a much greater extent than it did in March, as it seems obvious that this virus is not going away and we are going to have to live with it for a very long time.
There are now two main opposing camps; those who are for saving as many lives as possible, at all costs to the economy; and those who think the best way of increasing overall well-being is to keep the economy running, even if more people die. The second group think that politicians are prioritising saving lives (especially of elderly very sick people) at the cost of ruining the economy and blighting the lives of the young, especially the poor. Both are intrinsically worthy standpoints. How are we to be informed by science as to which is the better way forward?

To answer that, we have to assume that the longer the pandemic goes on, then the more likely we are to come up with both a good vaccine and good treatment to minimize the dreadful effects the virus can have on a minority of people. There is good reason to be hopeful here. As I have written before, I think good treatments are more important than a vaccine because that would attack the main problem – people becoming very ill, needing very high tech expensive medicine which overloads any health service – directly. Whereas a vaccine would depend on how well it protected people and what proportion would actually accept it. Treatments such as steroids, monoclonal antibodies and antivirals are coming on stream very quickly and they are all very hopeful. In fact a paper pre-published recently (12 4C) indicated that there has been at least a 10% mortality improvement in people admitted to critical care with COVID-19 in England, from 1st March until 30th May,

I have summarised my arguments on the question which is the best way forward in the next few pages. The references and further explanations following in an appendix so that people can look up further details as they see fit.


Covid-19 is a novel virus with unusual features. It mostly causes a mild illness, and can even be asymptomatic so that people don’t know they have it. But it also has the capacity to cause damaging and fatal illness in a minority of people who have underlying vulnerabilities; they are very elderly or suffer from certain illnesses which the virus has evolved to target -(1 7F) obesity, diabetes, hypertension, severe respiratory disease, and any condition where the immune system is compromised, such as cancer, and blood diseases. The illness that the virus causes is a multi-system disorder that takes a huge effort by healthcare staff to treat, and a sizeable proportion (now reducing) will not survive. This is a big problem because the load on any health service is impossible to sustain with existing human and other resources.* It would be the same as if meningococcal meningitis were ripping through the community, rather than occurring in its usual sporadic way.

The tried and trusted methods of managing any pandemic are test and trace for each individual case and restrictions of movement and even lockdown. But this will always entail huge downsides on the ability of people to earn their living and trade and distribute goods.

So I wanted to find a measure of comparing the benefits of saving as many lives as possible against the downsides (losses) of each individual person in a given community – a country, a large province, or similar. To do that I found a measure, WELLBYs, 2 which works out the average wellbeing of the total population in that community (involving economic and personal factors such as the effect of sudden unemployment, poverty, depression, loneliness; and other by-products of the situation or its management such as losses due to people not being treated with Covid using up all the medical manpower, or benefits such as reduced pollution under lockdown.

I found two studies using this measure, both done in late Spring 2020. The first 5 was done in Victoria in Australia, which showed that lockdown (at the time when it was being considered) would be three times as economically damaging as letting the virus take its course. The other was a forecast of when to relax the lockdown, using the same methodology. It too indicated that the sooner the better.

These two studies relied on a theory which was popular at the time, that letting the virus spread would soon induce “herd immunity”* 7 as more and more people became immune, while the the vulnerable could be isolated and protected. It has been promoted especially by those who value liberty and who point to the fact that the economic hardships tend to be concentrated in poorer communities.*

However this theory, though earlier supported by many governments, was soon found to have serious consequences. The first was the fact that in practice the the vulnerable could not be shielded, and died in large numbers.6. Secondly, even though many of these had never received any medical care during their illness in their care homes, or in their own homes, the medical services were still overwhelmed or at the point of being overwhelmed. 9 7F Staff were very hard hit, and without PPE many of them died. This was very different from flu where medical staff are confident of being able to continue despite a huge increase in workload. Thirdly,8 8G there was (and remains) the problem that the virus is far more infectious than originally thought, and spreads through droplets and fine particles (aerosols), often in living rooms at home as well as in large gatherings, and also is often spread without the person who has it knowing they are infected, so that they cannot take precautions.

So looking back on the original calculations in Australia and the UK, and recalculating, you would find that the inability to shield would increase the number of deaths excessively. Even though many of these deaths are given a low rating in WELLBY terms because there are fewer life years lost (the average age of Covid-19 death is about 80, close to general life expectancy), this still bumps up the loss side of the equation to high levels. Also the effects of health services collapse, with staff leaving, demoralised and ill, and behavioural changes in people fearful of getting the virus, would have a huge impact on the wellbeing of the population at large, and aggravate unemployment and poverty considerably. The ability of any state or government to cushion these effects would soon run out. I don’t think anybody has countenanced , nor should countenance the idea that we should choose not to treat people who wish to live.

Those are the calculations that spurred on nearly all governments in Europe, and partly in the Americas, to impose lockdowns and restrictions in various ways. They were acknowledged even by many economists.* However it was recognised that this could only be a stopgap measure as the costs in monetary terms would climb relentlessly. Governments are hoping for better treatments and the introduction of vaccines soon as there will come a time when insufficient economic activity will become financially insupportable for the population. Many people think that this time has already come, but economic analysis 3 Bis still on the side of trying to “flatten the curve”, as they say.

Do lockdowns make a difference? 2 7F Of course they do, but they can only be temporary. Their success depends on compliance in a population – if it is very good as it has been in Sweden, and also in the UK just before the March lockdown when most people saw the need for it, then the is very little need for coercion from governments. That is why Sweden 11 6E did well early on although it is now taking a hit as big as any. The objections to lockdowns comes mainly from the libertarian wing of human thinking. If you are philosophically of the opinion that people should not be compelled to do things against their will, even for the greater public benefit, then these arguments will not convince you. I am writing really for those who think lockdowns should be considered as part of the armamentarium of people concerned with overall public health.

Nobody living now has ever been in this situation before. It follows fifty or more years of medical progress, so that many people are in “medicated survival” – living good productive lives but dependent on medication (often promoted by drug firms, and sometimes caused by poor quality food and lack of exercise.) So one might think this crisis was bound to come soon or later, apart from the increase in the risk of pandemics through encroachment on ecological systems the world over. And it begs the question – should we all expect to live so long? We have imbibed the religious “sanctity of life” belief, which means we deny death if we possibly can. Will this pandemic lead to a feeling that perhaps in an overpopulated world we should be allowed to make our own decisions of how we would wish our lives to end, rather than let our deaths be dictated by pandemics? One more thought – over 20% of deaths have occurred in people with Alzheimers disease. Given that this cruel disease strips people of their personalities and causes great distress when they are deprived of familiar human contact, is it wise to prolong the agony? Is there a negative QALY – when living is worse than dying? If there were, the position of some of those with Alzheimers today might qualify.
Personally, if I were in a care home with Alzheimers I would rather see my family even though I might get Covid and die from it. In fact I would actively prefer to go that way than to let Alzheimers take its course.


Appendix.
1. 7*Countries worse affected by Covid were found to be characterised by higher obesity, high median population age, and longer time before border closures from the first reported case. Lancet study.
2. 7*Rapid border closures, full lockdowns, and wide-spread testing were not associated with COVID-19 mortality per million people.* Full lockdowns and high scores on the global health security scale for risk environment were significantly associated with increased patient recovery rates. So it is clear that countries vary considerably in their predisposition to having a lot of people suffering from Covid, and lockdowns do not necessarily help much overall (it all depends on at what stage lockdowns are put enacted). But that doesn’t tell you how to weigh up the benefits and harms of restrictions and lockdowns in specific circumstances.
3.7 Reduced income spread was found to reduce mortality and the number of critical cases.
4. WELLBYs 2 are a way of quantifying the good and bad effects of policy choices on all aspects of total human wellbeing, not only death but health, wealth, and satisfaction due to reasonable employment and social life, and project forward the effects of the two main competing viewpoints in the change in “years of human wellbeing” resulting from the policy. It begins with a question – “Overall, how satisfied are you with your life these days?” It is a measure of subjective wellbeing, how people feel about their lives, measured on a 10 point scale, with 0 being very dissatisfied and 10 being totally satisfied. It has been refined over the last 25 years so that it is now well-correlated with other measures and has strong predictive powers—it is, for example, one of the best predictors of life-expectancy. It is also reliable—people give consistent answers when retested. It is used extensively in many countries such as New Zealand and Australia to inform politicians and government officials on what course to take.
5. WELLBYs 5 cover a wide range of scenarios, so that for instance, a 10% change in income alters wellbeing by around 0.02 points (on the 0-10 scale). Sudden unemployment causes a drop in the well being score of 0.7 points. Depression causes a drop of There are tables that can give results for a whole range of outcomes. You then add a time dimension such as how long this event lasts, or a set endpoint, in this case a year, to give the change in wellbeing-years (or WELLBY’s).  This is similar to the concept of QALY’s (Quality-Adjusted Life-Years) and Disability-Adjusted Life-Years (DALYs) which are used by NICE to work out whether a new expensive drug treatment should be licensed in this country or not. The WELLBY’s concept widens this considerably, and 6 WELLBY’s = 1 Daly. At the moment average life satisfaction in UK is 7.5 (0-10 scale). If a person dies one year earlier the loss is 7.5. If they die 10 years earlier that is a loss of 75 WELLBYs.
6. Shielding. In March 2020 vulnerable people were told to “shield” or cocoon themselves, and unfortunately this proved disastrous, as cases ravaged care homes and households.The result was that the UK now has one of the highest death rates in the world. The fact is, it can’t be done. People already disabled enough to need care have to have actual people doing the caring, either in their own homes or in care homes. Those carers are low paid, and are often freelance for various companies so that they are in and out of people’s homes and care homes all the time. They frequently themselves had to isolate. The very expensive care homes were able to hold on to their staff by getting them to live in and not mix outside the home. But carers have families, and most cannot do that. Multigenerational homes in poor neighbourhoods cannot shield their vulnerable. At the beginning of the epidemic patients already in hospital who could be discharged were sent to nursing homes, but they weren’t tested to exclude covid infection. So they passed Covid on in a closed environment, and over 22,000 died. And where else could they be sent? If back home (often not possible medically) then they might spread the virus in the community; if another public step-down facility, the same would apply. Add the huge numbers of younger, working people with diabetes, hypertension, COPD, and asthma, who really can’t shield, you can see that this isn’t a strategy at all.
7. Herd Immunity. It was thought that there would be herd immunity if the disease was allowed to spread in the community willy-nilly. But as time has gone on it has become clear that herd immunity will never be reached with covid, primarily because immunity only lasts a matter of months, and then you can get it again. No country has got even near 60% immunity yet. Immunity in the elderly is always very weak because their immune systems are weaker. Herd immunity is never going to work for this. It has never been achieved for any disease without vaccination and you also need lifelong immunity (as you can get with measles). Vaccination is also quite problematic because immunity with coronaviruses tends to be weak and not to last long, and we know that some people will be reluctant to accept it.
8. Spread of virus. 8 We now understand that Covid spreads mainly by aerosols, very tiny particles emitted during talking and singing, as well as coughing and sneezing. These stay in the air for many hours unless the ventilation is good. Unfortunately, people can be infectious some days before they know they have symptoms, so they can spread the virus easily amongst family and friends, where social distancing is not possible. Mask wearing helps a lot, but people find it difficult to tolerate for long periods. So, transmission happens in people’s homes, in workplaces, everywhere where people congregate. Restrictions are well tolerated mainly by those who consider themselves at risk, but young healthy people have very little incentive to follow them, and lots of disincentives, such as the need to earn a living. Most people are gregarious and really enjoy other people’s company. It is a big ask if you aren’t likely to suffer from the consequences.
9. Health Service But the real killer for the idea that you can let the pandemic spread freely when cases rise, is that health services can be overwhelmed. We have to have a health service which will be able to treat everybody during and after the worst of the pandemic. I think that people who don’t have a link to the acute healthcare sector have no idea of the strain on the medical workforce in the last six months. Health workers are dreading the winter with intense anxiety as though something bad is going to happen, and they will have to risk their and their family’s lives again. The problem seems to be that, unlike some other infections, the severity of the covid illness is often dose dependent. If you are sitting in a room for several hours with an infected person, but do not get very close and there is no loud talking or shouting, then you may well get infected, but it may be a mild case of the disease. But if you are exposed to high levels of the virus day in day out in a hospital, you may well get very severely ill and risk death. Many of my friends towards the end of their careers are retiring early and others are looking to change to something safer. It is absolutely nothing like the flu. I worked through many flu epidemics, and got it through work, and it never bothered me or anyone else. Maybe some older doctors felt they had had enough, but generally speaking it wasn’t anything we thought about. When people really consider whether they would risk overloading the health services so that so many staff leave or get ill that you cannot guarantee that you can get timely treatment for anything, most people do think twice.
10 3 B Economists. “A comprehensive policy response to the coronavirus will involve tolerating a very large contraction in economic activity until the spread of infections has dropped significantly.
52% agree strongly 36% agree 5% uncertain
Abandoning severe lockdowns at a time when the likelihood of a resurgence in infections remains high will lead to greater total economic damage than sustaining the lockdowns to eliminate the resurgence risk.
41% agree strongly 39% agree 14% uncertain
Optimally, the government would invest more than it is currently doing in expanding treatment capacity through steps such as building temporary hospitals, accelerating testing, making more masks and ventilators, and providing financial incentives for the production of a successful vaccine.
66% agree strongly 27% agree 0% uncertain.”
11. 6E Sweden. If you look at excess mortality, considered to be a very good pointer to actual covid deaths (there are so many systems of counting deaths from covid that you can’t compare one country’s performance on their own figures), Sweden is faring well when compared to England and Spain, and only doing slightly worse than Switzerland, but much worse than neighbouring Norway or Denmark. And on the economy, Swedes’ decision to avoid going outside or spending – regardless of government mandate – meant that the expected advantage was not that great. Sweden is indeed a special case, but the picture does not lead to a conclusion that lockdowns are not a sensible thing to do;
12. 4C. On future treatments; there is better news. This is a fluid ever changing situation, and the equations in the studies above can be more hopeful in the near future. The first is that the longer the pandemic goes on, then the more likely we are to come up with both a good vaccine and good treatment to minimise the severe effects the virus can have on a minority of people. As I have written before, I think good treatments are more important than a vaccine (which would depend on how well it protected people and what proportion would actually accept it) because treatments would attack the main problem directly – people becoming very ill, needing very high tech, expensive medicine which overloads any health service. There is news now that the death rate and average length of stay in hospital with Covid has improved by 10% or more over people admitted to critical care with COVID-19 in England, from 1st March until 30th May, and this is continuing to improve, because of a much better understanding of how to treat patients. with oxygen and CPAP rather than ventilation, and also better drugs. Treatments such as steroids, monoclonal antibodies and antivirals are coming on stream very quickly and they are all very hopeful.

So let us assume that in six months time treatment will be much better. It seems reasonable to try to save as many lives as possible by restricting people’s activities but keeping in mind and quantifying the adverse effects, so that as soon as possible, when the two side are more equally balanced the restrictions can be easily removed.


References
2A https://blogs.bmj.com/bmj/2020/09/24/taking-a-wellbeing-years-approach-to-policy-3
choice BMJ
3B/https://www.igmchicago.org/economic-outlook-survey/ Chicago Booth
2Ahttps://www.bmj.com/content/369/bmj.m1874

4C https://www.nytimes.com/2020/10/29/health/Covid-survival-rates.html?action=click&campaign_id=154&emc=edit_cb_20201029&instance_id=23621&module=RelatedLinks&nl=coronavirus-briefing&pgtype=Article&regi_id=137171699&segment_id=42812&te=1&user_id=8889c0932a8d117d281ebd203a6a5cdf
4Chttps://www.medrxiv.org/content/10.1101/2020.07.30.20165134v2

https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers Australia

5Dhttps://parliament.vic.gov.au/images/stories/committees/paec/COVID-19_Inquiry/Tabled_Documents_Round_2/CBA_Covid_Gigi_Foster.pdf
6Ehttps://www1.racgp.org.au/newsgp/gp-opinion/was-the-swedish-approach-to-covid-19-really-a-mist
8Ghttps://english.elpais.com/society/2020-10-28/a-room-a-bar-and-a-class-how-the-coronavirus-is-spread-through-the-air.html?ssm=TW_CC&emailType=Newsletter
7Fhttps://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext
6E https://reason.com/2020/09/16/how-much-difference-do-covid-19-lockdowns-make/ Sweden
6E https://www1.racgp.org.au/newsgp/gp-opinion/was-the-swedish-approach-to-covid-19-really-a-mist