I recently realised that it’s still about two strategies. Though it’s something I knew at the start of the crisis, I had forgotten it recently, but in discussion of ‘exit strategies’ and hearing an expert talk about coming out of lockdown I was reminded that there are, still, two different strategies available.
I wrote this as I thought this might be helpful for others to understand – certainly media discussion doesn’t seem to appreciate these options, but perhaps this is widely known or other people are writing about it anyway.
(There is a shorter version of this post, less than 1000 words. This one is longer, with more words about the strategies, trade-offs and economics, and less editing.)
Two Strategies – Overview
There are essentially two strategies to choose against the coronavirus – though, of course, with a spectrum between them.
#1 is to suppress and eliminate the disease. The aim is to have few enough cases – perhaps even none – that it stops being a problem. Some countries have done this, either by shutting down at a very early stage, like New Zealand, so that there is hardly any community transmission, or by having a lockdown for long enough that the numbers decline to a containable amount, alongside containment measures.
#2 is to try and keep transmission and the number of cases low enough that it is manageable within the healthcare system. If your healthcare system has, say, 1000 intensive care spaces, and capacity for 100,000 tests, then you might try and stay below 5000 with the virus and 800 intensive care cases so that everyone who needs it receives adequate healthcare support. (I should be clear those are basically numbers I made up.) Thousands will still die, significant social distancing is still needed. Mass testing and contact tracing would also be very useful measures to limit exposure and provide good information.
(There is also strategy #3, which is to do little and deal with the mess as best you can. I’ll leave it out, but some countries or places are doing it, through choice or lack of other options.)
Two Strategies – More Detail
#1 would be to stay with severe measures, like ‘lockdown’, for
long enough to bring our new cases down to a very low level that
it can be contained going forwards –
a hundred or so, or
perhaps in the tens.
The reproductive rate needs
to be kept below 1.0, which might well mean that everyone still needs
some level of social distancing measures. The virus would still be
spread, but through contact tracing it might be possible to keep it
below 1.0, chasing the virus around the population and hopefully
catching it, invisibly, before someone has symptoms and before they
spread it. If it started to spread too much, distancing
measures across the whole population get enhanced again – which
might need to be for 3-4 weeks each time, because of the incubation
#2 is to get the number of cases to a controllable level, and then
seek to return to normal as much as possible. There would still need
to be significant social distancing measures, working from home, and
people not coming into contact with many different or new people.
But, if the current number of UK cases does not “overwhelm” the
NHS, then we might currently be on a sustainable number – if R<1.0.
strategies are to try and find a sustainable amount, but in
#1 might seem better, but would
require a much longer intense ‘lockdown’ period to get the number
of cases low enough. If
it works, then the
return can be quite close to normality, though it still needs some
measures like border closures or quarantines. It might also mean some
yo-yoing, if R because >1.0 and the 20 cases become 200 cases
again – but perhaps a year of bouncing between different
intensities of measures is better than a year of a medium amount.
#2 gets some level of normality sooner, but more people die of the
virus because the cases stay higher. It’s perhaps easier to
maintain, without bouncing around, because once you find the right
balance you stay there.
Spectrum, Mixtures, Measures
Each of those are models or essences of a strategy, and most countries will be somewhere inbetween them. It will also be different within a country. Within the UK, for example, some small islands are going for #1, and it could be described that for care homes, little enough was done it was somewhere between #2 and #3. Sweden has, from loose reports I have seen, brought in some limited measures, but seems almost closer to #3 than #2.
Measures are distinct from strategy, but are often confused. We’ve become so focussed on one measure – ‘lockdown’ – that strategies seem to have been forgotten somewhat. The measures do not distinguish: lockdown can be part of strategy #1, or strategy #2; both strategies need R<1.0; both seek to avoid ‘peaks’ and ‘spikes’.
What Next for The UK?
Understanding these two strategies is, I think, crucial for understanding the next stage. I think that calling it an ‘exit strategy’ is a mistake: there is no exit, there is only short term, medium term and long term. The UK – and other countries in similar position of a significant community transmission – have two choices, between strategy #1 and strategy #2. The choice is about trade-offs.
The UK has always been pursuing a version of strategy #2. Though it gets obscured by the fact that we went into lockdown, the plan of ‘flattening the curve’ (even without the words ‘herd immunity’ attached, which were something of a distraction anyway) was our plan from quite early on. In the interview where Johnson said that one option was draconian lockdown and the other was to ‘take it on the chin, as it were’, he said that he wanted a balance between the two. The Chief Experts talk of flattening the curve, not of eliminating the disease. The clamour now is to reopen to some degree as soon as possible – not to eliminate the disease.
still have a significant amount of coronavirus and community
transmission, because there are still enough people in contact with
each other at work, passing it within households (though that may now
be over), through care homes and hospitals, but it is on the way
down. We are not on exponential decrease, which is what would happen
if it is completely smothered; new confirmed cases seems about
static, but we have increased testing capacity, so it may well
actually be slowly declining, but daily deaths is on a gradual but
Choices and Trade-offs
It may be that something closer to strategy #1 would be better: lockdown for longer, reduce cases much more before returning to some level of normality. I might vaguely guess this to be the case, but I don’t actually have anywhere near enough information to know.
The choice of strategy includes many unknowns or uncertainties, such as how well smothering the disease would work and how effective containment can be long term. But it also includes moral choices – ones that our Government is playing with – which are about trade-offs.
One trade-off is between ‘the economy’ and ‘lives lost to the virus’. This is, largely, a nasty trade-off. Some have professed openly that we should sacrifice some people, but many have said this more implicitly, that it’s vital that we open things back up and get back to normal, and tens of thousands of deaths is worth it.
This benefits the status quo of corporations and financial capital, as well as the finances of those who survive. This is bad for those who die from the disease – elderly people, people with certain pre-existing health conditions, some social determinants. Those who are wealthy (and relatively safe from the disease), or left destitute due to a lack of work, favour this option. Those more at risk tend not to.
there is also a morally legitimate, though difficult, trade-off. This
is between ‘lives lost to the virus’ and ‘lives lost to other
things’. Lockdown measures do have a cost that isn’t just
health conditions which cannot be treated while the focus is on
coronavirus intensive care. There
will be some economic effects which may cost lives, which I’ll
return to. Lockdown itself will have effects, a form of iatrogenics;
if it has significant effects on wellbeing, that will shorten lives
across the board; and I don’t know if people are on the whole
healthier, eating more healthily, sleeping better and getting more
exercise in the current situation or not, but it could have a
Economically, it is the case that poverty is bad for health, in general. The economic cost to our economy of coronavirus and the shutdown will be significant, and could cause much more unemployment, as well as weaker growth. This would, usually, affect wellbeing, lives lost and the length of lives. The last decade, for example, alongside stagnant wages for the lower-earning sections of society, has had a reduction in life expectancy for the lower-earning sections of society. Economic growth is, generally and with some caveats, good for life expectancy and wellbeing.
The counter-argument to this is that this is not inevitable – and this is correct. The generally overlooked aspect of economics is distribution. Within the status quo neoliberal or capitalist lens, distribution is not even part of economics, and it is a fact of life that people buy and sell in a certain way and wealth moves in a certain way. The truth is that things could be different, and the last decade could have avoided making things worse for the least worse off. Distributed differently, public services would not have need to be cut, and economic effects could be born the most by the wealthiest so that those already in poverty or vulnerable situations do not regress further.
I don’t want to go into the politics of economics further here – this post is already too long for an overview of the ‘Two Strategies’ – save to say one more thing. Realistically, this redistribution is unlikely, and so the economic effects will cost lives. Though I will put my energy into it, and hope that my prediction is wrong, it doesn’t seem that we’re about to see a socialist society as part of our future with and beyond Covid-19. Therefore, this trade-off, and those deciding on the trade-off, do make these calculations.
Thoughts, comments, questions, disagreements and corrections all welcome. If you are an editor who might want to publish an improved version of this post (which was only written to my blog standard!), get in touch!