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8 January 2021

Devi Sridhar: The UK needs a zero-Covid strategy to prevent endless lockdowns

To avoid restrictions next winter, the UK must seek to eliminate the virus, not merely suppress it, argues the Edinburgh professor of global public health.

By George Eaton

Throughout the Covid-19 pandemic, Devi Sridhar has been a voice of bracing clarity and urgency. I first interviewed and profiled the Edinburgh professor of global public health last October, discussing the false choice between “saving the economy” and “saving lives”, and we spoke again following the announcement of the second national lockdown. Following the imposition of a third lockdown, we spoke once more on how the UK can escape perpetual crisis.

The UK, not for the first time, has intervened too late against Covid-19. Why does this keep happening? 

We don’t have a larger strategy beyond lockdowns to protect health service capacity alongside vaccines to help solve that problem. At the press conference three days ago, you could hear [chief medical officer] Chris Whitty saying we’ll probably have restrictions again next winter and I feel that’s quite a fatalistic strategy, which is this is a virus, we have no control over it and we have to react when the virus does something instead of having a proactive strategy. We know enough from the last ten months to say how we are going to solve this, so that by next winter we aren’t in another lockdown with rising unemployment as well as another thousand deaths a day, which is just appalling at this point [UK daily deaths reached a record 1,325 on 8 January]. 

We really need a three-phase strategy: right now, it’s survive winter without the NHS collapsing, it’s that basic, and get your restrictions in place and have compliance, it’s your crude, harsh catastrophic lockdown because you’ve got to hammer those numbers to try and make sure that hospitals don’t run out of oxygen and people are not dying because they can’t get care, not just from Covid but from anything. 

And then in the next phase, as we enter spring, we should hopefully get our numbers down, get a really functional test and trace system, as well as isolation, the emphasis on isolation and paying people to isolate to get numbers down and compliance up.

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Then the summer really has to be about following the East Asian and Pacific model of elimination and then protecting that by telling people they cannot travel abroad, which they [the government] are saying, if you listen to the language it’s shifted, they are saying don’t take non-essential journeys abroad whereas if you listened last summer it was “go abroad on holiday”.

What does the UK need to do to ensure this lockdown works? 

First, we need compliance and you can already see from the mobility data that it’s reduced because people are tired and it’s winter and there’s fewer opportunities to meet outside and a lot of people are thinking they have to go to work because they’ve suffered financially for so many months under these restrictions that they need to earn. 

I don’t worry about compliance in terms of people being intentionally risky but in being forced into a compromise position where if your choice is whether to earn and try to get yourself out of the pit you’ve been in for ten months, and then risk getting Covid, your worry will be financial at this stage, especially if you’re in a younger, healthier category.

I don’t think even tracing makes sense with 60,000 cases a day, but mass testing is still valuable so people know if they’re positive. Some of my friends in London tell me that results take a few days, we’ve got to make that faster. Scotland’s test results take about 24 hours but we still need to get that turnaround time faster because if people know they’re positive they’ll go quickly into isolation. 

Added to that, we need to support people in isolation, ten days, especially if you’re going to face loss of income and if you can’t work from home, is a massive ask for people and this leads to people not getting tested – because you’d rather not know if you’re positive.

In New York, I’ve been joining their Covid advisory group meetings, and the three things they’ve done which really boosted compliance is paying people generously to stay home as an act of goodwill. Then offering practical support: they’d even offer pet care, they will offer medicine, they will pick up your groceries, whatever you need to make your life better. The third thing is they’re offering hotel rooms in the city to try and break household chains, so if you’re living with flatmates and you don’t want to risk infecting them and they test negative, you can go somewhere else to isolate. 

Finally, it seems the government’s finally talking about border measures: we’ve not tested anyone coming in but I am worried about a new strain being imported and then going back to stage zero if that makes sense. We need to make sure we have not just testing at airports but real quarantine procedures, because testing isn’t perfect, the minimum we should be doing is asking people to have a negative test result coming in and that costs you nothing, or you can do testing when people arrive. The only way to be sure is to monitor and enforce isolation either at a hotel or at home.

Will the new lockdown have to last longer than seven weeks? 

Yes, because we are running such a high level of infections, one in 30 in London, one in 50 in the UK, those numbers are astonishingly high and we need to get them down to a level at which hospitals are not overwhelmed and the test and trace system can keep a handle on it.

Testing and tracing works very well with small numbers of infections or concentrated outbreaks and that’s what we learned in Scotland this summer where we had pretty much stopped community transmission but there were flare-ups. There was an outbreak among 20 different hospitality venues in Aberdeen and so test and trace, along with targeted restrictions, managed it within two weeks. But if you have widespread transmission then tracing doesn’t make sense any more, you basically want to test people and then get them to isolate.

The first lockdown succeeded in reducing cases and deaths. Where did the UK government then go wrong?

From a Scottish perspective, the sequencing data that has come out recently has shown that the first strains of the virus were eliminated. We were practically Covid-free but we then had new strains come in from holidays and tourism, the movement of people, and so that was what generated the second wave. 

And elsewhere in the UK, the south-east was doing really well and then all of a sudden it exploded and of course that’s through movement of people into that area. We’re seeing the same thing on the Scottish islands, many of them were Covid-free before. 

The other thing is that England opened up really fast and the case numbers probably weren’t low enough and it didn’t have a functional test and trace system. It’s almost as if they’re driving a car and they’re accelerating as fast as possible to get the economy going, with Eat Out to Help Out, until the last possible moment when hospitals are going to collapse and then they brake and then everything stops and then as soon as they feel that they’ve got hospitals under control they start accelerating as fast as they can. 

I think the lesson is “slow and steady”, which means you open up slowly. The same is true of aviation, they [the government] were really worried about aviation in the summer, so they pushed holidays, “get abroad”, support airlines, but actually what’s happening to airlines now is 50 countries banning flights from the UK because of the new variant, so it’s not sustainable.

The same with hospitality, Eat Out to Help Out was successful at getting people into restaurants but that was just a month and now many of them are not going to survive. The more credible thing would have been to say we know hospitality is going to be an issue because night clubs, bars and pubs, we know these are very conducive to viral spread, so how do we develop a sustinable support system for these businesses, so that they stay alive without adding to the public health risk? They could have said to people support local businesses, get takeaway, and given grants to these businesses. They could have done it more creatively, rather than subsidising the most risky behaviour [eating out] you could possibly have.

Should the UK have pursued a “zero Covid”​ strategy? 

This is the question and I hope people now understand what I was trying to say last March. The choice for us living in this country is would you rather have your daily life back meaning everything that you want in terms of bars, pubs, sports matches, concerts, live music, theatre, arts, but with the consequence that you can’t travel abroad and you’re stuck here with the other 66 million people on this island as your pool of social connections, or would you rather be able to go abroad and do whatever you like but live under restrictions for the foreseeable future.

And that’s the difference between living with the virus and eliminating the virus and, for me, I would put aside my own selfish interest in wanting to see family and friends abroad because I know for the vast majority of people, their jobs and their livelihoods, and for children in school the better option is to eliminate the virus.

At the moment we have rising unemployment, we’re going to be in a deep recession, so many businesses can’t operate, people say it’s the restrictions killing the economy, I keep saying, no, it’s the virus. There is no way, unless we get a handle on the virus, that we can run this economy. I do worry when Whitty keeps saying this is endemic, that we have to live with it, it’s seasonal, we have to accept a certain number of deaths next winter, it’s impossible to eliminate it. And my response is it’s theoretically impossible to the modellers but it’s practically feasible for other countries and now having seen it in Scotland, we did it last summer, so we know we can do it, we need more ambition, it’s a failure of imagination, it’s a failure to protect the British population at a time when we need the government to step up.

Do you think restrictions will be required next winter? 

It would be a massive failure if we’re in the same position next winter, this for me would be catastrophic. A winter lockdown with thousands of people dying a week and we’re saying this is the best we can do, it makes absolutely no sense, we should be aiming higher and for better, and we need a government which is willing to aim high and actually go for it. It’s almost as if they’re afraid to set a lofty goal and achieve it, they’re setting the bar so low that of course it becomes a self-fulfilling prophecy.

Why has the UK been so lax in relation to Covid-19 border control? 

It makes no sense to me how you have a government that ran on taking back control of our borders and at a time when you actually need it, from a public health framework to protect the people living in Britain, you don’t use it. 

If you look back at Sage and Nervtag minutes they didn’t advise the government to put in place border protections but that was because they were following a flu model, which is “everyone is going to get it anyway”. You can delay it by a week with restrictions, you can delay it by three weeks but in the end we may as well get it over with and, even to this day, there’s a belief that elimination within national borders makes no sense because we can’t cut ourselves off from the world forever. 

But increasingly what you’re going to get is a division of the world with some countries such as Britain cut off because they have such high infection rates and in a way we’re becoming isolated, which is what we didn’t want, because we’re not actually lowering incidence, whereas places like New Zealand their people can fly anywhere in the world because they have no risk of bringing Covid with them. To be an island in 2020 or 2021 is probably the greatest geographical gift you could have.

Boris Johnson keeps promising a return to normality and is continually proved wrong. Do the vaccines mean we now have genuine cause for hope?

It’s cautious optimism, it’s another tool in our armoury, we have another weapon against this virus, but right now it’s almost being used as a Hail Mary, which is if we didn’t have the vaccine we’d really be sunk. And it’s great that we have this, but we shouldn’t overpromise on what the vaccines can and cannot do and there are still major questions over how long protection lasts, whether it stops transmission, whether it protects against all strains, and if you want true herd immunity, as with MMR, you probably have to vaccinate 80-90 per cent of the population, we’re far off that, it hasn’t been trialled on children yet, especially teenagers who can circulate and spread the virus. 

The fastest way through this crisis would have been last spring to form a strategy for elimination, gone for zero Covid over the summer, held that lockdown for a bit longer, told people they couldn’t go on holidays and then be back to normal by September/October within your borders. That was the fastest way through it, and now people are saying lockdowns are horrible, but we might as well do it properly now instead of being in repeated cycles of lockdown.

Until we do lockdown properly we are going to be stuck in this, and that’s what people don’t get, governments have no chance but to go into reactive lockdowns if their health services are collapsing because people will die in their 30s because they can’t get oxygen or because they’re having a heart attack and that becomes a failed state and so this is where I blame these Covid deniers, or not even Covid deniers, but people who say it’s like the flu, or there’s no second wave or lockdowns are terrible. We all agree lockdown is terrible but they’re forcing us into this because they’re eroding compliance and they’re eroding confidence in govt measures to suppress the virus. 

The result is we’re having rising infection levels, which is forcing us into a lockdown, so the lockdown is actually being pushed by the people who are anti-lockdown because they don’t understand the hospitalisation rate of this virus. I am gutted we are in another lockdown right now.

[See also: How the UK lost control of the mutant strain of Covid-19]

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