As the UK prepares to exit lockdown, it has passed its peak for deaths due to COVID-19. In India, on the other hand, lockdown is scheduled to ease on June 8, despite the fact that the number of cases in the country continues to rise. Iran, meanwhile, is bracing for a second wave of deaths after initially easing its lockdown in April.
How do governments decide whether to reopen or whether to stay locked down? These decisions are partly based on political ideology, as we have seen in Brazil, but also relate to the physical infrastructure that is available to tackle the crisis, as well as the timing of the original lockdown.
It’s also important to remember the four types of negative impacts related to coronavirus:
- Direct COVID-19 deaths;
- Deaths that occur because the health system becomes overwhelmed;
- Delays to routine and other non-emergency healthcare due to lockdown measures, or to people not seeking medical support;
- Longer term impacts on health and mortality as a result of the subsequent economic downturn.
Using the UK to illustrate: the health system successfully mobilised enormous capacity, including 33,000 beds in existing hospitals - a third of all existing beds - and opened up to ten new field hospitals for COVID-19 patients.
This, combined with lockdown measures, limited the number of direct deaths and ensured the health system didn’t become overwhelmed. However, there has been a significant cost in the form of preventative, routine and other non-emergency healthcare being postponed.
The negative impact of this is emerging, with early data indicating an increase in non-COVID cancer deaths, but the full toll is not yet understood.
Similarly, we don’t know the longer term impacts on health and mortality as a result of the decline in the economy, which could be 35% in the UK in the second quarter of 2020. But it is well accepted that income has a significant impact on health.
This is particularly important as it is a sad truth that those in lower socioeconomic groups will be disproportionately affected – and thus inequalities will widen – the longer the pandemic and control measures continue. It will be a similar story in other countries.
Developing an exit strategy
In the absence of treatment drugs or vaccines, countries need to develop exit strategies to ease lockdown measures and continue to control the pandemic. Widespread testing and contact tracing combined with social distancing measures currently look like the only viable way to control the epidemic in the absence of a vaccine.
Both the World Health Organization and the European Commission have produced guidance, which include three requirements for lifting restrictions. First, disease transmission should be under control with a reproduction number below one.
Second, a country needs sufficient capacity to test, track and trace every potential case. The better the testing and tracing, the less all-embracing social distancing needs to be, because infected people are routinely isolated from the population. In theory, contact tracing could replace distancing altogether. Finally, the health system needs to have the capacity to cope with a potential second wave.
As countries are beginning to ease restrictions, some are prioritising certain industries such as small retailers, hairdressers and construction sites, while others are prioritising schools. In the main, bars and restaurants are remaining closed or severely restricted – in Paris, terraces have opened for drinking and dining but customers are not allowed to sit inside, for example. What is common is that those easing restrictions are doing so in stages, supported by science.
As the pandemic proceeds, lockdown measures should become more targeted. This should be based on continuing to protect the most vulnerable, including those in care homes, and supporting the people experiencing the worst economic effects first. This includes children, where school closures are adversely affecting the poorest the most, and Black, Asian and minority ethnic communities.
It is clear that we will be living under the cloud of COVID-19 for months, if not years. It is also clear that individual behaviour will be crucial to control the spread. But as countries move to the next phase of this pandemic, we suggest the following transition to a new and improved business as usual that goes beyond the personal.
A just transition
Faced with COVID-19, healthcare systems across the world have achieved what would have previously been thought impossible or taken years, with innovations such as virtual clinics. As we emerge from lockdown, we need to consider what we can achieve in other spheres.
Before COVID-19, the biggest threat to human health was global warming. During the international response, air pollution and fossil fuel consumption have dropped across the world. This has shown us what is possible.
Now, the way out of one crisis is not by expediting the next one with increased fossil fuel energy use in an attempt to boost recovering economies. National governments have given unprecedented financial support to business and industry. The required quid pro quo should be that business and industry develop new business-as-usual plans that make their contribution to the Paris climate agreement.
If we simply return to business as usual, we will not have honoured the hundreds of thousands of lives, including thousands of healthcare workers, that have been lost.
The transition from COVID-19 lockdown needs to be a rebirth into a healthier, fairer and greener world. A new and improved business as usual.