Is it safe to come out?

The media is currently obsessing over when precisely we will be able to stop social distancing, self isolation and quarantine and the many subtle variations on this. The press is hungry for a date, something to work around, some beacon on the horizon for the readers. The concern is that, faced with too distant a date, people may simply disobey.

It’s a very real possibility but, at the same time, it cannot be justified on current medical evidence. Shutdown was initiated on March 23 at which point in time there were 6650 cases of coronavirus, an increase of around 1000 on the previous day. So if we assume that a daily occurrence rate of 1000 new cases per day is enough to shut down the country, it makes sense that a similar figure should be the earliest point at which we consider scaling down the shutdown and starting to open up again.

You can be sure that, once businesses are reopened, there will be an upsurge in the number of cases. How big an upsurge is hard to predict but, if everybody follows their oft declared intention to party, the rise may be sufficient to reinstate the lockdown.

But even 1000 new cases per day hardly amounts to a medical victory. Projected over the summer, that would amount to around 200,000 cases by autumn and around 8,000 deaths. Far from being a medical victory, the figure is more a pragmatic and political decision weighing into the equation the profound sociological, political and economic damage resulting from shutdown.

On purely medical grounds alone, one would wish to keep the social distancing measures in place until the daily caseload had fallen way below 1000. It is currently around five times that figure. If it takes as long to get the caseload down to 1000 as it has taken to go from 1000 up to the present 5000, then lockdowns will continue, on medical grounds alone, for another 3 to 4 weeks. And all of that is based on the premise that 1000 new cases per day was enough to trigger lockdown and therefore would be enough to trigger the cessation.

In all probability, the epidemiologists and statisticians, making their decisions on purely medical grounds, would rather see a much more substantial and sustained reduction in the number of cases than the token 1000 per day. The politicians doubtless view it differently and will be pressing for an earlier release, if only to preserve those businesses that are hibernating rather than simply going to the wall. Already economists are predicting the worst recession in 300 years.

There is of course also the sociological damage. We have never before had occasion to incarcerate the entire country’s population. But that’s fundamentally what we are doing. Social isolation means exactly that and will be a test (is already a test) for the more mentally fragile of our society. What happens when we unlock those dark chambers? Are we ready for the tsunami of mental illness that will likely follow? Primo Levi once said that a major cause of death amongst the Jews post-Holocaust was suicide, often triggered by an inability to understand why they had survived but others had died. There was guilt for being amongst the saved rather than the drowned.

Each of these three caucuses (medical, sociological and economic) doubtless have different ideas of when it will be best to relieve the lockdown. Clearly each must have their say. And all of these factors must be weighed in the decision to be taken, I’m sure, as a compromise between the needs of all three aspects.

From a purely medical stance, one would not, out of preference, remove the lockdown until either significant herd immunity was in place or a reliable vaccine was in place. Herd immunity can only occur when the majority of the population has immunity. In order to achieve this, much of the population has to be infected. If we knew we could fight the infection confidently with anti-viral agents that would perhaps be our preferred course of action. But the problem is that we have no effective treatment for the illness and therefore to infect the majority of the population is simply not an option. Unless of course one is prepared to accept a death toll in the region of 2 million (don’t even think about it, Boris).

So we have no effective antivirals. What about the vaccine, I hear you ask. I’ve been impressed by the sheer number of people who have said that a vaccine will be here by the end of the year. I think they are perhaps confusing hope with reality. We would like it to be here by the end of the year but that’s not the same thing. But let’s look at our record. As far as I know we have never successfully produced a vaccine for any coronavirus (and yes, there are others – the common cold for instance). So we’re back to square one – our only weapon against coronavirus is to cut of the route of transmission, which means social isolation. The problem with social isolation is that not only do you cut off the route of infection but you also prevent the development of herd immunity. And if you have no herd immunity through infection, the only way is to generate immunity by vaccination and we are still a long way off. Isolation prevents transmission but it also means that people do not have immunity. It’s a catch 22.

In truth, the only solution will have to be one that balances social, economic and medical dimensions. In order to save the economy, we may have to accept a certain level (and likely a high level) of mortality to preserve society. In the end comes down to the disparity between the rationales for imposing and lifting the lockdown. We made the decision to impose a lockdown on purely medical reasons. Economic and sociological implications were given barely a thought. And nor could they have been – the mood of the populace called for action. The government more or less had to respond. But as the lockdown has bitten hard, it has become apparent that we simply cannot sustain a lockdown on medical grounds which might last as much as a year. At that point there would be no economy left and that itself will have taken a toll in terms of suicides and deaths due to deferment of routine and nonroutine surgery and medication. Either way lives will be lost due to coronavirus whether explicitly or secondarily.

Some seriously tough decision making ahead. And I wouldn’t want to be in Boris’s slippers.