Professor Chris Whitty; CMO, England

Dr Frank Atherton; CMO, Wales

Dr Gregor Ian Smith; CMO, Scotland
Dr Michael McBride; CMO, Northern Ireland
Professor Patrick Vallance; Chief Scientific Officer,

Subject: COVID-19 policy response (an open letter)

20th September 2020

Dear CMOs

We write to express our grave concern about the emerging second wave of COVID-19.
Based on our public health experience and our understanding of the SARS-CoV-2 virus, we
ask you to note the following:

1. We strongly support your continuing efforts to suppress the virus across the entire
population, rather than adopt a policy of segmentation / shield the vulnerable until
‘herd immunity’ has developed. This is because
a. Whilst Covid-19 has different incidence and outcome in different groups,
deaths have occurred in all age, gender and racial/ethnic groups and in
people with no pre-existing medical conditions. Long Covid (symptoms
extending for weeks or months after Covid-19) is a debilitating disease
affecting tens of thousands of people in UK, and can occur in previously
young and healthy individuals.
b. Society is an open system. To cut a cohort of ‘vulnerable’ people off from
‘non-vulnerable’ or ‘less vulnerable’ is likely to prove practically impossible,
especially for disadvantaged groups (e.g. those living in cramped housing and
multi-generational households). Many grandparents are looking after
children sent home from school while parents are at work.
c. The goal of ‘herd immunity’ rests on the unproven assumption that re-
infection will not occur. We simply do not know whether immunity will wane
over months or years in those who have had Covid-19.
d. Despite claims to the contrary from some quarters, there are no examples of
a segmentation-and-shielding policy having worked in any country.

Notwithstanding our opposition to a policy of segmentation-and-shielding, we

strongly support measures that will provide additional protection to those in care
homes and other vulnerable groups.

2. We share the desire of many citizens to return to “normality”. However, we believe

that the pandemic is following complex system dynamics and will be best controlled
by adaptive measures which respond to the day-to-day and week-to-week changes
in cases. “Normality” is likely to be a compromise for some time to come. We will
need to balance suppressing the virus with minimising restrictions and impacts on
economy and society. This is the balance that every country is trying to find – and
every country is having to make trade-offs. This might mean moving flexibly between
(say) 90% normality and 60% normality. We believe that rather than absolute
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 measures (lockdown or release), we should take a more relativistic approach of
more relaxation/more stringency depending on control of the virus.

3. Controlling the virus and re-starting the economy are linked objectives; achieving the
former will catalyse the latter. Conversely, even if policies to promote economic
recovery which cut across public health objectives appear successful in the short
term, they may be detrimental in the long term.

4. As evidence accumulates for airborne transmission of the SARS-CoV-2 virus,

measures which would help control the virus while also promoting economic
recovery include mandating face coverings in crowded indoor spaces, improving
ventilation (especially of schools and workplaces), continuing to require social
distancing, and continuing to discourage large indoor gatherings, especially when
vocalisation is involved. With measures like these, much of society will be able to
function effectively while keeping the risk of transmission relatively low.

5. As we move beyond the acute phase of the pandemic, it is important to restore

routine medical appointments (e.g. for long-term condition review and patient
concerns that may indicate new cancers). We believe that a combination of remote
appointments (online, phone and video) plus face-to-face appointments with
appropriate personal protective equipment will allow this to happen safely. We
recommend a communication campaign to inform the public that the NHS is now
open for most routine business.

6. In a complex system, we should not expect to see a simple, linear and statistically
significant relationship between any specific policy intervention and a particular
desired outcome. Rather, several different policy measures may each contribute to
controlling the virus in ways that require complex analytic tools and rich case
explanations to elucidate.

7. Whilst it is always helpful to have more data and more evidence, we caution that in
this complex and fast-moving pandemic, certainty is likely to remain elusive. “Facts”
will be differently valued and differently interpreted by different experts and
different interest groups. A research finding that is declared “best evidence” or
“robust evidence” by one expert will be considered marginal or flawed by another
expert. It is more important than ever to consider multiple perspectives on the
issues and encourage interdisciplinary debate and peer review. Whilst government
must continue to support research, some decisions – as you will be well aware – will
need to be made pragmatically in the face of uncertainty.

We thank you for your continuing efforts to get us through the pandemic.

Professor Trisha Greenhalgh OBE PhD MD FMedSci FRCP FRCGP FFPH FHEA FCI MBA (Chair
of Primary Care Health Sciences, Oxford University)

on behalf of
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Dr Nisreen A Alwan MBChB MRCP FFPH PGCAP FHEA MPH MSc PhD (Associate Professor in
Public Health, University of Southampton)
Professor Debby Bogaert Debby Bogaert MD PhD (Professor of Paediatric University of
Edinburgh)
Professor Sir Harry Burns KBE (Professor, University of Strathclyde and Past Chief Medical
Officer, Scotland)
Professor KK Cheng BSc MBBS PhD FRCGP FFPH FMedSci (Professor of Public Health and
Primary Care, University of Birmingham)
Dr Tim Colbourn BSc MSc PhD (Associate Professor of Global Health Epidemiology and
Evaluation, UCL Institute for Global Health)
Dr Gwenetta Curry, BS MS PhD (Lecturer of Race, Ethnicity, and Health, College of Medicine
and Veterinary Medicine, University of Edinburgh)
Dr Genevie Fernandes BA MA MSc PhD (Research Fellow, University of Edinburgh and Action
Team Member, Royal Society's DELVE Initiative)
Dr Ines Hassan MEng EngD (Senior Policy Researcher, Global Health Governance
Programme, University of Edinburgh)
Professor David Hunter MBBS MPH ScD FAFPHM (Richard Doll Professor of Epidemiology
and Medicine, University of Oxford)
Professor Martin McKee CBE MD DSc FMedSci (Professor of European Public Health, London
School of Hygiene and Tropical Medicine; Past President, European Public Health
Association; Research Director, European Observatory on Health Systems & Policies)
Professor Susan Michie FAcSS FMedSci (Director of UCL Centre for Behaviour Change,
University College London).
Professor Melinda Mills MBE FBA (Director, Leverhulme Centre for Demographic Science,
University of Oxford; Member of Royal Society’s SET-C (Science in Emergencies Tasking –
COVID) committee; Member of ESRC/UKRI COVID Social Science Advisory group)
Professor Neil Pearce PhD DSc FRSNZ FMedSci (Professor of Epidemiology and Biostatistics,
London School of Hygiene and Tropical Medicine)
Professor Christina Pagel PhD MSc MSc MA MA (Professor of Operational Research &
Director of the Clinical Operational Research Unit, University College London)
Professor Neil Pearce PhD DSc FRSNZ FMedSci (Professor of Epidemiology and Biostatistics,
London School of Hygiene and Tropical Medicine)
Professor Maggie Rae PrFPH FRSPH FRCP Hon FRSM (President, Faculty of Public Health)
Professor Stephen Reicher FBA FRSE FAcSS (Professor of Psychology, University of St
Andrews)
Prof Harry Rutter MA MB BChir MSc FFPH FRCPEdin (Professor of Global Public Health,
University of Bath)
Prof Gabriel Scally (Visiting Professor of Public Health, University of Bristol)
Professor Devi Sridhar, BS MA MPhil DPhil (Chair of Global Public Health, Edinburgh Medical
School)
Dr Charles Tannock MBE MA MBBS MRCPsych PhD (Hon) (Consultant psychiatrist)
Prof Yee Whye The PhD (Professor of Statistics, University of Oxford)