So, here we are the end of England’s Lockdown 2. Lockdown, the word of the year, was supposed to be a one-off as we ‘learned to live’ with COVID-19 until the white knight of a vaccine arrived over the nearest hill. Yet the second lockdown was near-inevitable due to the nature of COVID-19 and the attempts in the UK to control it. This is why.

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“So what do you think should be done about COVID-19?”

Chances are you’ve asked, or been asked, this, probably over Zoom, as your region moved up a Tier or as you contemplated a Christmas without being able to see all of your nearest and dearest. Maybe you were worried about your favourite business or wondering what on Earth a substantial meal is. Or perhaps you’re concerned about University students locked in their halls living off food parcels. Then it all seemed for nought as England entered a month-long lockdown.

It doesn’t mean you’re a COVID-19 conspiracist or a mask-debater; you’d have to have your head in the sand to not be confused or worried about the UK’s response to the pandemic. Stay home, protect the NHS, save lives became ‘Eat Out to Help Out’ before it became easier to list the regions not in Tier 3 before Lockdown 2 arrived.

As U-turns go, the Prime Minister’s has been the screeching, handbrake on kind. Boris Johnson first went against scientific advice and resisted a ‘circuit breaker’ three-week lockdown. Leader of the Opposition Sir Keir Starmer committed his party to pressurise the government to U-turn.

Then other countries, inside and out of the UK acted. The Republic of Ireland, after similar resistance, announced a six-week lockdown. Wales went into a shorter two-week‘ firebreak’. France and Germany announced new lockdown measures.

Then, Johnson U-turned and announced a month-long lockdown for England from the 5th November. Flanked by Chief Medical Officer, Chris Whitty and Chief Scientific Officer, Sir Patrick Vallance Johnson painted a grim picture on 31st October. Two key slides showed how projected daily deaths exceeded the government’s own reasonable worst-case scenario and how the NHS capacity would be exhausted.

Yet the government has its detractors. Some of Johnson’s own MPs have formed a group, the sardonically named COVID Recovery Group, to impose further lockdowns. They allege that the cure of lockdown is “worse than the disease” and advise that we “live with COVID-19” until mass vaccination is a reality. There is talk of a new political party aimed at opposing lockdowns.

The lockdown sceptics have presented their argument. The Great Barrington Declaration, funded by the American Institute for Economic Research, a libertarian think tank, was published on 4th October 2020 and advocates focused protection for those people most at risk of COVID-19 whilst allowing others to live as normal. Included in its list of signatories are ‘Dr Person Fakename’ and ‘Harold Shipman’. It’s been estimated that about half of its supporters on social media are fake bot accounts. Despite this in response, ten days later, came the John Snow Memorandum advocating a continuation, or even extension, of lockdown measures. So, what to believe?

The simple fact is that in one way or another the UK, like the rest of the Western North Hemisphere world, has tried to “live with COVID”. To try and balance ‘business as usual’ with public health measures. New Zealand, on the other hand, went for ‘zero COVID’ or ‘COVID eradication’. This involved a rapid shutdown, closing the borders and a “level 4 lockdown” which meant that people could only interact with people within their home. New Zealand eradicated COVID-19 and, despite some small outbreaks, have achieved a successful economic and public health outcome. This strategy was based on the experiences of Asian countries with the SARS pandemic. The idea was to take COVID-19 cases to zero. In the UK we have tried to suppress COVID-19 to low levels but not tried to eliminate it. We tried to live with it, with a mixture of opening up the economy whilst applying local restrictions. The result was more cases and more restrictions.

One of the central tenants of Medicine is informed consent: the ability of patients to make decisions regarding their care based on being presented with all available information. This article will try to do just that: present what the information and what ‘living with COVID-19’ means.

The case against lockdown

The first argument against lockdown is economic. The chancellor Rishi Sunak has spoken of his “sacred responsibility” to balance the country’s books. Yet thanks to COVID-19 the UK’s GDP has plummeted to record depths. More on that later. The next arguments come regarding the people most at risk of the disease.

Public Health England broke down the cases of COVID-19 in each age group. For both men and women, the majority of deaths have been in the over 85 age bracket. For women, this age group has also seen the highest excess mortality compared to the 2015–19 average. For men, the highest excess mortality was in those aged 75–84. What is interesting is that in both men aged over 75 and women aged 75–84 the number of deaths due to COVID-19 exceeded the expected mortality. This means that other expected causes of death actually went down.

Breakdown of COVID-19 deaths by age-group in England to week ending 18th September 2020, Source: PHE

This trend is seen across multiple agencies studying the effects of COVID-19. Despite Boris Johnson promising a protective ring around care and nursing homes, the Office of National Statistics (ONS) estimated about 26,500 excess deaths in care homes and 23,500 excess deaths at home in comparison with the 2015–19 average for March to 7th August.

Why should young university students be stuck in halls because of a virus which is a bigger threat to the elderly? Why should we shut down the economy and hit working-age people? We can’t pretend that lockdown is some benign experience. The impacts on mental health, education and other non-COVID healthcare aspects may take years to become fully apparent.

The NSPCC have reported record calls to its helpline during lockdown. A study from the London School of Hygiene and Tropical Medicine has found an increase in breast, lung, oesophageal and colorectal cancer deaths. The British Heart Foundation have identified 2085 excess deaths in England and Wales due to stroke and heart disease. The National Blood and Transplant Service reported reductions in donor referrals and transplants.

This, sadly, is not an unusual phenomenon seen in the response to a disaster. Following the terrorist attacks of 11th September 2001 it was estimated that there were 1600 extra deaths on American roads due to people avoiding flying. In response to one threat, we can often go willing into the arms of another. Of course, what isn’t apparent is to what extent this ‘collateral damage’ could have been avoided with planning and foresight. We’ll come to that later.

Research from Imperial College London estimates the risk of dying from COVID-19 for someone infected aged between 10 and 20 at 0.006%. For someone aged 40–49 the risk becomes 0.15%. If you’re aged over 80 it’s 9.3%; nearly one in ten.

Here comes the argument of ‘shielding’ the most vulnerable allowing the young to restart their lives. Others are far blunter: any lockdown only postpones death, it doesn’t prevent them. What’s the point? It’s time to learn to live with COVID-19. To develop herd immunity. To treat coronavirus like influenza; part of the fabric of life. But what does this mean?

We have vaccinations and central heating. Yet influenza and winter still kill a lot of people.

Influenza makes an easy comparison to COVID-19. Donald Trump and his Brazilian counter-part and political soul mate Jair Bolsonaro have both made the comparison in a typically crass fashion. Both diseases affect the upper respiratory tract. Both are spread primarily through droplets of respiratory secretions. Both are of greatest risk in the elderly and those with pre-existing co-morbidities. We don’t shut down for ‘flu so why should we for COVID?

The UK government tracks influenza and each year produces an annual report of that year’s ‘flu season’. They are all free to access here. The data collected tells us that from the winter of 2015/16 to week 9 of 2020 56,461 people died in the UK of influenza.

Influenza is a disease with which we have “learnt to live”. A disease for which we can offer proven vaccinations to those patients most at risk. Yet 56,461 people in the UK have died of influenza in the past 5 years. In the single worst winter, 2017–18, over 20,000 people died. These numbers are likely to be an underestimate given that not every patient with influenza is tested.

England and Wales Excess Winter Deaths, Source: ONS

Something else we have ‘learnt to live with’ is winter itself. Yet winter is associated with an increase in mortality due to factors such as infections and the cold. An increase in mortality for a period of time compared to the historical average is known as excess mortality. The Office of National Statistics (ONS) reports that the winter of 2017/18 saw 49,410 more deaths in England Wales than the five-year average for winter. For the winter of 2018/19, they estimate an extra 23,200 deaths.

Despite modern medicine, heating and knowing full well what winter involves it has killed over 70,000 people more than expected in just two years.

COVID-19 has killed more people in less than a year than influenza has in five

UK Influenza Deaths, Source: PHE compared to UK COVID-19 Deaths, Source: WHO

So, having ‘learnt to live’ with influenza and winter how does COVID-19 compare? At the time of writing the World Health Organisation (WHO) reports that there have been 58,245 deaths in the UK due to COVID-19. This is far greater than the recorded UK deaths due to influenza in any one winter. In fact, it is greater than the total recorded influenza deaths for the past five winters. The WHO figure could be an underestimate. The ONS records COVID-19 deaths if the disease is mentioned on the death certificate not only if there is a confirmed positive result. The ONS estimate that there were 51,935 deaths due to COVID-19 in England and Wales up to 7th August. If correct this is only 4,526 less than the total deaths due to influenza since 2015/16.

England and Wales Excess Winter Deaths compared to England and Wales Excess Deaths March-August 2020, Source: ONS

The ONS estimates excess mortality of 58,000 in England and Wales for early March and 7 August 2020 compared with the 2015–19 average for the same period. This again is far greater than the excess mortality seen for the 2017/18 and 2018/19 winters. Between January and August, 2020 COVID-19 was the underlying cause of death for three times as many patients as influenza and pneumonia in England and Wales.

COVID-19 has a far greater burden on healthcare than influenza

Of course, mortality is just one way to measure the impact of a disease. Another is how poorly is makes patients and the level of care they require. In this regard again COVID-19 has a greater impact.

Total Influenza ICU Admissions in England and Peak Weekly Admissions for 2018-19, Source: PHE compared to COVID-19 ICU Admissions, Source: Gov.uk

During the 2018–19 influenza season, a total of 2,924 patients in England were admitted to intensive care in England due to the disease. At its peak, 287 patients were admitted in one week to an intensive care unit due to influenza. In comparison at the peak of the first wave of COVID-19 on the 12th April 2020, 2,881 patients in England were in intensive care requiring mechanical ventilation. On 2nd April, ten days after the first lockdown was announced, 1,494 patients were in intensive care in England for mechanical ventilation due to COVID-19. By 1st September this had fallen to 59. By the time Johnson announced a second lockdown, just over eight weeks later, it had risen to 815 patients. It has continued to rise. At the time of writing there are 1,417 patients in England in intensive care for mechanical ventilation due to COVID-19. ‘Living with’ COVID-19 is not the same as ‘living with ‘flu’

Other aspects of COVID-19 also make any attempt to ‘live with it’ very difficult. Asymptomatic patients may unwillingly spread the disease to the vulnerable. It’s also worth pointing out that it is not as if COVID-19 is benign for younger people. The extent of ‘long COVID’ is still becoming apparent.

Recently work was published looking at results from the COVID Symptom App which gives an idea of the extent to this condition. 88% of Italian patients hospitalised with COVID-19 report symptoms 2 months later. 55% of French patients report fatigue 110 days after being hospitalised with COVID-19. Although younger people are at a reduced risk, cases of multi-organ failure have been seen in children and young people infected with COVID-19. Oxford University performed MRI scans on COVID-19 survivors and found post-infection changes to the lungs and other organs including the brain. We don’t know if in a few decades time long-term consequences may be revealed in younger people infected with COVID-19 today. To this raft of physical symptoms comes news of mental health problems being reported in survivors of COVID-19.

The virus isn’t becoming ‘less deadly’ and herd immunity isn’t happening (without a vaccine)

While SARS-CoV-2 is slowly mutating the implications of this are not clear. There is no evidence that the virus is becoming ‘milder’. The Financial Times global database found that those countries which suffered the most in the spring seem to be becoming hotspots in the autumn again.

The implications of the new ‘mink variant’ remain unclear. If anything, the risk may be greater; the virus mutates to a form untouchable by vaccines in production, rather than becoming ‘milder’. Nor are we becoming immune ‘naturally’.

Herd immunity describes the number of individuals in a population who would need to be immune to a disease (either through vaccination or previous infection) to prevent transmission to vulnerable non-immune people. Each disease has a different proportion needed, 95% in measles, for example. The WHO estimate that about 70% of the population would need to have immunity to COVID-19 to confer herd immunity. There is no evidence we are anywhere close to that target. Even Sweden, held up as an example for lockdown sceptics, has not received that target with one recent study in the Journal of the Royal Society of Medicine finding evidence of immunity in just 15%. Imperial College London has reported that antibody prevalence in England is falling, not rising.

Sweden is an example, but not a good one

A more detailed examination of Sweden’s COVID-19 shows some uncomfortable truths. While they have recorded fewer deaths per million compared to the UK (most countries have) they dwarfed their Nordic neighbours. Once lockdown was first announced in the UK deaths per million actually fell below Sweden’s.

The country’s public health agency has recently admitted that their predictions about a second wave in Sweden were wrong following a surge in cases.

The systems we needed haven’t worked

The story of the Track and Trace programme has not been a happy one. 15,841 positive cases went untraced and had to be retrospectively added to the caseload. Looking at the most recent data on the Track and Trace system tells us that 40.1% of contacts of cases were not being reached. When the ONS launched its COVID-19 survey in May 51% of households signed up. That number has now fallen to 5%. Johnson’s much-vaunted ‘moonshot’ rapid testing trial failed to identify COVID-19 infection in over 50% of cases.

Going into how the government has awarded contracts and positions of responsibilty could be an article in of itself. The bizarre story of Michael Saiger is perhaps the most potent example of how the government has sought to answer the pandemic. Saiger, a Miami- based jewellery designer, earned £200 million in contracts from the UK government before paying £21 million to a Spanish businessman, Gabriel Gonzalez Andersson, to act as a go-between and source PPE. More on the economic response later.

Shielding would be near impossible

The idea of ‘shielding’ the elderly sounds simple and honourable but in reality, would be deeply impractical. Data from Age UK reveals that a third of households in the UK are headed by someone aged 65 or over, 19% of carers are themselves aged over 65 and one in five people aged 50 to 64 in the UK are a carer. Cutting off the older age group from society would be impossible. This is without mentioning the ethical concerns of sacrificing older people for the sake of the economy, not to mention other issues. Sweden recently lifted restrictions on the over-70s citing the physical and mental consequences of social isolation.

What about at-risk groups? Public Health England’s report, Disparities in the risk and outcomes of COVID-19, makes for sobering reading. People of Chinese, Indian, Pakistani, Other Asian, Black Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British. Should all these people shield? Working-age males diagnosed with COVID-19 were twice as likely to die as females. Should all men shield? It’s a non-starter.

Economy vs lives is not an argument

Opponents of further lockdowns use the argument of how much economic pain is worth saving lives? It’s a facile argument because the opposite question can easily be posed: how many deaths are worth protecting the economy? This is not a zero-sum game. According to data from the Financial Times economic impact of COVID-19 has been worse the poorer a country has been at controlling the disease. The two go together not as separate strands.

True, the economic impact of COVID-19 has been huge. Some of this has been due to the UK’s poor pandemic preparation. For example, The National Audit Office has revealed the price of sourcing PPE due to an inadequate stockpile. Between February and July this year, the Department of Health and Social Care spent almost £12.5 billion buying PPE that would have cost £2.5 billion before the pandemic.

As the UK’s economy is set shrink by 11.3 per cent in 2020 and the government would need to borrow £394bn to fund a shortfall in taxes and £280bn in public spending the fact is the money hasn’t been well-spent. Compared to other G7 countries the UK is set to spend over 80 per cent more, with a 90 per cent deeper decline in economic output in 2020 and almost 60 per cent more deaths. The reason appears to be delays in both the spring and autumn to impose lockdown with the result being harsher measures undermining the economy.

With the focus on COVID-19 it is easy to forget that in five-or-so weeks time will come the end of the UK’s transition period with the EU and the full impact of Brexit will hit. So easy, that Sunak did not mention it during his spending review statement. Yet for all the pain COVID-19 has wrecked the economy with the London School of Economics and the Office of Budget Responsibility both predict greater harm from the UK leaving its largest trading bloc.

It is predicted that by the end of 2022 COVID-19 will have resulted in a 1.7% decline in GDP. In other words, the pandemic will cause a nasty, but short impact. However, leaving the EU with a trade deal will cause a 4.9% decline in 15 years time. A no-deal Brexit would cause the economy to shrink by 7.6% in 15 years. One hopes that those MPs pushing against lockdown on economic grounds will be as vigilant in pushing the government to ensure as close a deal as possible to the EU.

What does ‘postponing death’ even mean?

This cuts to the very nature of modern medicine. It is a fact of the human experience that death is ultimately unavoidable. As a doctor should I therefore not stop a patient dying from a heart attack because I’m merely postponing the inevitable? This is a question broader than just COVID-19. The fact is that while life expectancy has improved, the time spent in health has not improved as much. We have added years to life and not life to years.

However, delaying a pandemic is a good thing. It’s not just about saving capacity in a health service it also buys time for research. It buys time to improve care. A meta-analysis and systematic review (the highest level of scientific evidence) of intensive care units in Europe, Asia and America found that mortality amongst their patients with COVID-19 fell by a third from March to May.

In other words, if the lockdown delayed you contracting COVID-19 by just three months from March to May your chance of survival improved from nearly 40–60 to 60–40. It doesn’t sound like much but it would do if you were the one about to be admitted and wanting to know your chances. It also buys time to trial new initiatives such as mass testing in Liverpool.

Let’s look again at that data from Public Health England which broke deaths from COVID-19 into age groups. 25.4% of deaths due to COVID-19 were recorded in patients aged 0–74. Hardly insignificant. However, life expectancy at birth in the UK in 2017 to 2019 was 79.4 years for males and 83.1 years for females. If we look at deaths in people aged up to 84 we see a different picture: 57.8% of deaths.

In other words, nearly 6 out of every 10 deaths were in people within life expectancy. At what point has someone lived ‘long enough’ and the fact they didn’t reach life expectancy become meaningless?

The way out

The ultimate step to successfully defeat COVID-19 will be vaccination. Through lockdown and other social distancing measures, the idea is to reduce the number of people infected whilst this key weapon is developed. On Monday 9th November Pfizer and BioNTech announced that initial results for their vaccine: an astonishing 90% efficacy rate. This vaccine was produced in a novel way which could pave the way for faster vaccine production in the future. However, the vaccine currently requires two doses three weeks apart and has to be sorted at about minus 75 degrees Celsius.

Shortly afterwards Moderna announced the results for their vaccine: 95%. Once again, their vaccine requires two doses but refrigeration at a more manageable, but still extreme, minus 20. Oxford Uni-AstraZeneca then published their data: 62–90% efficacy improved by giving 1.5 doses rather than 2. Their vaccine only needs standard refrigeration at 2 degrees. These announcements are what we have been waiting for.

Final approval for vaccines will require time as will planning on how to overcome logistical issues of storage and overcoming vaccine hesitancy. There are also other vaccines in production. This is what the time lockdown gives us can do. There will be people alive to be vaccinated who wouldn’t have been without lockdown.

Lockdown also works. Non-pharmaceutical interventions such as staying at home and closing businesses have proven very effective at limiting the spread of COVID-19. The inverse is also true. Any relaxation means an increase in transmission. Data shows that by cutting long trips in particular lockdown limits transmission. It is a harsh medicine but necessary. All the more bizarre then the government’s Christmas bubble idea. A political decision with little Public Health behind it, it risks a lot. It’s sad that the message with it was that it was the season “to be jolly careful”. Hardly clear.

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Boris Johnson grew up wanting to be ‘world king’. In December 2019 as he won a historic election a few cases of atypical pneumonia in China would have been the last thing on his mind. 2020 wasn’t supposed to be like this. This was supposed to be the year of Brexit finally delivered and of a new levelling up agenda. But this is what leadership is all about. Tony Blair won a second landslide on 7th June 2001 yet his whole premiership would be redefined on September 11th that year. Gordon Brown came to power in 2007 little knowing that the prize he’d lusted after for a decade would be wrecked within a year by the credit crunch. You don’t choose the circumstances. When the inevitable inquiries come into how the UK responded to the COVID-19 pandemic our leaders have to own the decisions they made and explain how and why they came to them. That is leadership.

It might also be wise leadership to explain how the UK went from a leader in pandemic planning in 2008 to the situation we are in now. To explain why we were so poorly prepared for a pandemic that the health service was unable to meet usual demand as well as face COVID-19? It might also be wise to detail the extent the findings of Operation Cygnus, the pandemic planning exercise in 2016, were used to shape policy. What was learnt and what was forgotten?

Finally, in a bid to end on a positive note it is important to look at just what we have achieved this year. When the Black Death hit the British Isles in 1348 it would be another 500 years before the cause was identified and another century before a cure was available. It took 80 years to identify the virus behind ‘Spanish ‘flu’. When HIV/AIDS first appeared in 1981 it was 3 years before the virus behind it was identified and another decade before a reliable treatment was available. In one year we have gone from a new disease to identifying the virus, sequencing its genetic code, finding a reliable treatment for the most severe cases and now have multiple vaccines available. This is astonishing. We should be proud of what we have got right. We should also learn from the things we got wrong.