Comment
Offline: The path out of lockdown
“Just read your paper. Hmm...it reads well, until you
try and imagine what it actually will mean in practice.”
This response was from someone who understands
well the burden of mental trauma this pandemic is
causing. His objection to the argument for Zero-
COVID was that it seemed to endorse “the greatest
imposition of restricted civil liberties ever seen in
peacetime”. Indeed, during World War 2 cinemas,
theatres, cafes, restaurants, and pubs all remained
open. He concluded: “If I was allowed to vote on this
Brave New World, I would reject it firmly...We now
teach every medical student that patients have the
right to make their own choices, even when they are
bad ones, and even when they inevitably lead to their
own demise.” My friend has powerful support. Writing
in The Mail on Sunday last weekend, former Supreme
Court Justice Lord Jonathan Sumption argued that
Zero-COVID was a “mirage”, that lockdowns were “a
sinister and untried experiment”, and that “we must
learn how to live with [this] disease, as our ancestors
have always done.”
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What, then, is a sustainable way out of lockdown?
Take the UK as an example. If one looks at the average
number of cases per 100 000 population (using 7-day
averages), the UK mean rate peaked on Jan 4, 2021,
at 641·9. The latest reported rate (Feb 3) is 208·6, a
67·5% decline. If the UK maintains its existing lockdown
measures, community transmission could largely be
halted towards the end of February. If suppression is
stable for several weeks, one could envisage some
easing of lockdown mandates by mid-March. There
are several caveats. First, the predominant virus
variant in the UK is now the more transmissible
B.1.1.7 strain. The course of decline in transmission
may not be as linear as I am assuming. Second, we
are still living through winter, when conditions
favour household transmission if social mixing has
inadvertently caused infection in a family member.
Third, continuing falls in community transmission
depend on public support, which cannot be taken
for granted. Finally, there is vaccination, and surely
vaccination will enable an early spring opening to be
virtually guaranteed.
www.thelancet.com Vol 397 February 13, 2021 565
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This conclusion seems entirely reasonable. 15 million of
those most at risk of serious illness in the UK are on track
to receive a first inoculation by Feb 15. Once vaccination
has been translated into immunity (early March), the
Karim Jaafar/AFP/Getty Images
protection of the most vulnerable, temporally combined
with very low levels of community transmission, will
give compelling force to more libertarian voices who
wish to see the earliest possible reopening of society.
Israel’s experience lends support to this view. Those who
undergo vaccination seem to benefit from an accelerated
decline in new cases compared with those who are
unvaccinated. But those advocating for an early end to
lockdown may be premature in their optimism. Even
assuming that no new variant takes hold (the South
African 501Y.V2 or B.1.351 lineage, with its E484K spike
mutation, has been identified in the UK) and that vaccine
supplies remain uninterrupted, the scale of the challenge
facing the UK has been underestimated. The UK Joint
Committee on Vaccination and Immunisation has
identified a further 16 million people older than 50 years
at risk of serious COVID-19. It will take at least until
May 6 before they receive a first dose of vaccine. At
Frantzesco Kangaris/Getty Images
that point, 30 million people across the UK will still be
susceptible to infection. Lifting lockdowns and risking
the virus surging back will put a proportion of those still
to be vaccinated in danger. This moment will mark the
transfer of power from scientists back to politicians. It
will be at this point that a serious public conversation will
have to take place. Do we continue physical distancing,
with persistent disruptions to schools, universities,
workplaces, and leisure activities, until about three-
quarters of the population are immunised (achieving
herd immunity) or do we agree that a finite number of
deaths must be accepted if we are to return to relatively
normal lives? Our society has normalised deaths from
many diseases. Why should COVID-19 be any different?
In England, deaths from influenza vary from several
thousand to as many as 30 000 per year. The question
politicians will have to answer is this: what number of
COVID-19 deaths are they willing to accept? And will
Claire R Greenway/Getty Images
the public trust their answer?
Richard Horton
richard.horton@lancet.com