Published 27 April 2020
Lockdown is the new pandemic. It played its vital role in reducing the spread of the disease and keeping the front line safe, but its harsh effects are causing avoidable harm. Non-Covid-19 mortality is higher as people are not getting essential health care, whether through fear, choice or lack of access. Diagnoses and interventions are not being made that would save lives now and in the future.
The health system of tomorrow is looking ever more challenged from its growing ‘to do’ list and the economy to pay for this recovery is on borrowed time and money.
A vaccine is not imminent and nor are antivirals to reduce the health risk posed by Covid-19. ‘Test and trace’ did not work in the early days of the pandemic and is unlikely to offer a convenient exit – even if it is turbocharged by the tech firms.
There will be no imminent exit from lockdown. So, to protect the health and wealth of the nation, it must evolve.
While there are unknowns, it is known that the disease spreads through respiratory droplets and results in a mortality rate of around 1%. The excellent work of the last month could quickly be lost if a carrier of the disease sneezes on the Underground.
Small steps need to be taken against a backdrop of risk and, seemingly, low confidence in the public to collude effectively. These small steps include protections, processes and policies. Protections include:
Personal face masks, which could be cloth, to stop people spreading the disease (e.g. from a sneeze) – particularly in densely populated locations (e.g. public transport)
Relatively low-cost temperature checks to help identify the 71% of infected people that have a fever to reduce the ability for the disease to spread unknowingly
Frequent disinfection of high-risk surfaces in public or high transit areas to complement on-going efforts to get people to wash their hands
Technology to help trace contacts for confirmed cases or warn people in an area if there is an outbreak (“red” day) that warrants and nudges more significant social distancing efforts
Continued shielding of the vulnerable population, which should be refined over time as more is understood who is vulnerable from the disease
These should form part of a developing toolkit to be used against Covid-19. It should be common to see people wearing masks and cleaners cleaning.
Alongside these protections, various locations need reopening to the public to enable economic recovery to begin. These include health centres, transport systems, schools, places of work, and society in general. Infection risk at these is unavoidable, so pragmatic processes are needed to minimise risk. These processes will ideally become a form of etiquette like queuing inline, which the British public excels at demonstrating even under social distancing rules.
Hospitals, GP surgeries and care homes are high risk due to both the likelihood of infection and the presence of vulnerable people. Mandatory mask-wearing and increased frequency of cleaning would enhance the systems already put in place, such as hand sanitiser stations.
Shared transport systems are core for the economic recovery in cities. Still, they concentrate too many people, and networks make it near impossible to track connections where the disease may spread. An initial allocation of travel permits (e.g. two return trips per week) and bookable travel slots would help to reduce the density of people while allowing some return to work. Temperature checks at stations and within interchanges combined with increased cleaning and requirements for mask-wearing would help to reduce the risk further.
School closures have a particularly negative effect both on the economy of today as parents time is distracted and of tomorrow as the development of children is slowed. The impact will be inequitable. Evidence suggests children are lower risk but have the potential to spread the disease. Furthermore, phased reopening for cohorts (e.g. two longer days per week) to reduce class size combined with temperature checks and protocols for antibody testing if the infection is suspected would help to reduce the spread of the disease.
Places of work (offices, factories, etc.) like schools create risk. Some can operate to a greater or lesser extent remotely. Others, such as factories, should be reopened as a priority, but with safety measures – similar and coordinated with school schedules, so that households are out for the day. Given the risks, steps should be put in place to prevent individuals from being coerced back to work when it is unsafe.
Bars and restaurants may face the biggest challenge in reopening, particularly where their economic model is built on high-density seating and fast turnaround times. These may need more significant restrictions and support in the medium run, although they should be allowed to innovate in how they operate. Some have moved to take-away only, but others could reopen with measures in place to distance patrons through arrival slot booking, app ordering and shielded tables.
Social distancing under the blunt tool of lockdown has worked, but it has isolated some and put others at risk from domestic challenges. The concept of a “household” works well, so should be extendable to allow the creation of virtual households (e.g. up to five people) and perhaps small networks that will enable communities, including work ones, to be rebuilt over time. These would complement test and trace by restricting social movements.
Data collected from "test and trace" would help refine the understanding of potential risks and opportunities to relax aspects, such as increasing the allocation of travel permits. This would need to be couched within a policy framework, which allowed rapid course correction to account for unforeseen effects or risks. Equally, measures should be no more restrictive than needed.
More is now understood about the potential impact of a “second wave of Covid-19” on the health system. The time to bolster the resources to mitigate this mortal risk to the health of the nation is now. The complexity of this alongside responding to growing and unmet health needs will be challenging and may take several years of work. The wealth of the nation will be critical in funding this recovery.