The second lockdown buys us time. We must use it

As the UK enters its second lockdown, there’s less sense of déja vu than might have been expected. Nothing has changed for the virus: the infection curve has (even adjusting numbers for the greater extent of testing this time round) the mathematical precision of the classic second wave. But it is spreading in a different social climate. Whereas in March there was a general sense of relief when the government finally (and belatedly) committed itself to a national lockdown, and a feeling of unity in the face of the crisis, this time there is a volatile and fissiparous mix of emotions and responses: anger, fury, despair, desperation, confusion, all against the nerve-wracking backdrop of events across the Atlantic that could determine the future of western democracy.

In March there were a few sceptics who doubted that such severe restrictions on individual freedoms were necessary or desirable. Now those voices have swelled to something approaching a political movement—and which opportunists like Nigel Farage are mobilising as precisely that. For a populist government like Boris Johnson’s, the dilemma is agonising: to hitch your flag to this bandwagon, which would require Trumpian levels of science-denial, or to heed the statistics plainly telling you that without new measures, the death toll could be even worse than before, but in doing so surrender your self-image as a defender of personal liberties (like going to the pub)?

Characteristically, the prime minister managed to choose the worst of both worlds: opting for a lockdown (and trying not to call it that) too late to avoid what is likely to be several thousand more unnecessary deaths, while unwittingly feeding the conspiracy theory that he has been forced to capitulate to a scientific community that is fabricating Covid-19 figures for unspecified personal gain.

It’s hard to find an aspect of the coronavirus crisis that the British government has not made worse. There’s the Treasury’s clumsy attempt to kickstart the economy by subsidising one of the worst spreading activities—eating out—which now seems likely to have fuelled infections in the late summer. There’s the car crash of the Test-Trace-Isolate (TTI) system that was supposed to save us from another lockdown, but which failed at the crucial moment when schools returned and infections began inevitably to climb. There’s the failure to engage with and challenge the false narrative that pits lives against livelihoods—as the Financial Times has pointed out, countries that experienced the worst casualties have tended also to take the hardest economic hit. There’s the undermining of public compliance with restrictions catalysed by Dominic Cummings’s flouting of lockdown rules. And there’s the steady stoking of culture wars by ministers and their sympathetic media, which has fomented widespread distrust of government and “elite” scientific advice even among Johnson’s supporters and party and which, abetted by the tier system of local Covid-19 measures that alienated the north of England, has left the country feeling more divided than ever. Anger at the national lockdown is in itself understandable, since it was surely avoidable.

All this bodes poorly for what is to come. A second wave of infection was always going to be likely—one can’t blame the government for that, as the experience of much of Europe has showed. That we face it once again so ill-prepared and literally behind the curve is, however, inexcusable, not least because similar inaction and procrastination in March almost certainly increased the mortalities in the first wave. Even for a government so adept at squandering public funds on underperforming private contractors, it was some feat to so completely exhaust the immense fund of public and political goodwill it was offered in the spring.

But this is where we are. Whether or not there will ever come a moment of reckoning and accountability, the priority now is to make best use of the time that a lockdown of several weeks should buy. Whatever some cynics say, the summer lockdown was not entirely wasted: testing capacity, so vital to monitoring and controlling the spread of coronavirus, was expanded significantly, to a level comparable with that of many other European nations. (Although it still wasn’t enough to cope with the demand in early autumn, the problems there were partly about incompetent management of logistics, infrastructure, messaging and IT.) Work also progressed swiftly on new testing technologies that offer fast, on-the-spot results—especially the method known as LAMP (loop-mediated isothermal amplification) for detecting viral DNA, which is incorporated into a test developed by Oxford Nanopore that can deliver results in 15-20 minutes from saliva samples. These devices have been trialled in hospitals, and as Johnson intimated in the press briefing last Friday, they are now ready to be deployed on a large scale.

“I think now is precisely the time to deploy rapid LAMP testing,” says molecular geneticist Andrew Beggs, who leads testing efforts at the University of Birmingham. People “will effectively be fixed in place with much reduced mixing, so hotspot areas should be targeted to rapidly test focused populations.” The problem with the standard swab tests used so far, which are analysed by the Lighthouse labs newly created for the purpose, is that they are slow: even without the September backlog that all but broke the testing system, results can take around four days to arrive, during which time people might be mixing and spreading infection.

Beggs recommends that rapid LAMP testing now be used not just in regions of high prevalence of Covid-19, but on all staff in hospitals and care homes, whether or not they have symptoms—asymptomatic spreading has been one of the biggest problems in the pandemic. This “really needs to start as soon as possible,” argues Beggs—but he says public health authorities might need persuading and reassuring to take on this new technology.

Testing is only one part of the containment strategy, though. The Independent Sage group, set up after concerns were raised about the breadth and autonomy of the official Sage team that advises the government, has argued that the entire Test-Trace-Isolate system needs improving and rethinking. Short of that, however, Christina Pagel, a specialist in modelling and operational research in health care at University College London who participates in Independent Sage, says that urgent improvements are needed in the trace and isolate stages.

“You need to be asking contacts of new cases to isolate within three days, maximum, of the new case being tested,” she says. “That means getting test results in less than a day, finding their contacts in less than a day, and contacting their contacts in less than a day. Currently, we are nowhere near that.”

Contact tracing has been a neglected part of the chain: it “always feels like the Cinderella at the ball,” according to Ewan Birney, Deputy Director General of the European Molecular Biology Laboratory. In fact, the proportion of people reached by contract tracing seems to have been declining as the number of infections soars—in early October just 62 per cent or so of the close contacts of people testing positive were reached. Here, local health protection authorities are performing much better than centralised call centres and online services—perhaps in part because people are more likely to respond to an unknown caller if the number is local. The performance could be improved by implementing “backtracing,” as is done in Japan, where tracing teams work out if two or more people who test positive have histories that intersect at risky locations—suggesting that everyone else in that place at the same time should also be contacted and testing. But that too depends on local knowledge.

All of that is of limited use, however, if people do not isolate properly. “Surveys estimate that only 20 per cent of people with symptoms are fully isolating, and only 10 per cent of contacts,” says Pagel. “It has to be much higher.”

To encourage that, Pagel says that rather than imposing huge fines for failure to comply (a strategy said to be favoured by Cummings), there should be more provision for lost wages (Independent Sage suggests increasing the £500 currently offered to £800, for two weeks). She also calls for accommodation with meals and access to care if required (say, for people living in housing where isolating is difficult), and support for caring responsibilities and buying groceries (the main reason people break self-isolation). She says there should be home visits or daily phone calls to check if people are isolating and if they need support to stay inside, and to check on their symptoms.

We can also use this time, Pagel says, to better prepare public and communal environments—especially schools, which may need to improve ventilation and distancing measures. Schooling might need to become more flexible—by, for example, using any available empty buildings to boost classroom space, and introducing “blended learning,” where half the class stays at home on any one day (with support for disadvantaged children who may lack access to laptops or Wi-Fi). Restaurants and pubs should be financially supported to improve ventilation too, she says.

What might be harder to turn around is the woeful state of leadership and public trust. I have been told several times that one of the biggest obstacles to a properly functioning TTI system is the use of private companies which do not have the requisite experience in public health. It’s a lethal irony that a government so committed to the virtues of private enterprise and the free market has managed so visibly to illustrate its deficiencies (not least, that “freedom” is vulnerable to inefficient cronyism). The government also needs to make proper use of local expertise in a more devolved system. What we have seen instead is not just an instinct to bypass the local in favour of the centralised, but what has seemed like willful determination to seek confrontation with local authorities.

Aside from these deep-seated problems, will the current lockdown measures be enough to stem the alarming rise in cases and buy more time to do things better? Pagel says they should get the R number (a measure of the spreading rate) below 1 pretty quickly—which would turn a growing problem into a shrinking one. “We should start to see cases dropping within seven days or so,” she says. But there are still unknowns in that equation, in particular the effect of keeping open schools and universities. “If cases have not come down in two weeks after lockdown, then possibly we might need to close schools for about a couple of weeks,” says Pagel.

So there’s a lot to be done in rather little time, and considerable uncertainty about how it will turn out. Best not make plans for Christmas just yet.