key: cord-0803973-ehnjl6cz
authors: Vedhara, Kavita
title: COVID-19 Second wave: Lockdown should not mean lock-up
date: 2020-11-09
journal: Public Health
DOI: 10.1016/j.puhe.2020.10.031
sha: 66fad41634e501e0436544be165ceabfdea1a0fc
doc_id: 803973
cord_uid: ehnjl6cz

nan

On 23 rd March 2020, the UK introduced a national lockdown with the intention of suppressing the first wave of COVID-19 infection. This lockdown included school and university closures, closure of all retail and hospitality and severely restricted access to all but the most urgent health and social care. The subsequent toll on physical and mental well-being, educational attainment and the economy was both unprecedented and catastrophic.

Several months later we find ourselves staring into the abyss of a second wave. This was not inevitable, with some countries having thus far experienced no or minimal second waves of infection. 1 But we are here, and so it is incumbent on us to learn the lessons of the first lockdown and examine the ways in which a second one could be reconfigured to mitigate the worst effects of the first.

In less turbulent times, the way we would approach this would be to understand not just the science, but the priorities of the public and the outcomes that matter to them most. 2 Sadly, we do not have the luxury of time. Nonetheless, it is imperative we start this discussion now: if not to influence the dimensions of a second lockdown, then for the ones that may follow and of course future pandemics.

In the interests of starting this dialogue we can hypothesise some areas that are likely to be priorities, based in part on what we know about the priorities typically espoused by the voting public, 3 and the sectors of society that were immediately and most visibly affected by the pandemic.

Education: The closure of schools and universities demonstrated their central role in keeping society functional. Without them parents could not work (even at home); there was widespread disruption of educational progress in children and young adults; increased risk of emotional and physical harm, food insecurity and the associated impact on mental health have all been well documented. [4] [5] [6] [7] As education is clearly the fulcrum on which our current and future well-being and economic prosperity lies, all efforts must be made to ensure that it is able to continue.

What have we learnt about the disease and our responses to it that could help us achieve this? Several discoveries are key. First, social distancing cannot be easily achieved in places of education as evidenced by the fact that both school and university openings have been associated with an increase in infections. Second, that for up to 80% of people the disease will be asymptomatic or only mildly symptomatic; and that these individuals are capable of passing on the infection. 8 Third, certain contexts may be associated with an increased risk of infection (e.g., secondary schools, halls of residence). 9,10 These insights alone tell us that infection is very likely to occur in educational settings and could spread rapidly. This surely indicates that a comprehensive, rapid and recurrent asymptomatic testing programme would enable education to continue. It would ease pressure on symptomatic testing, which currently cannot satisfy demand; would reduce the need for bubble, year or entire school/university closures while suspected symptomatic cases of COVID await test results; and critically would permit early detection of COVID-19 infection and, in turn, break cycles of transmission.

Health and social care is another likely priority for the public. The one clear objective (some would say only) from the start of the pandemic was to 'protect the NHS' to ensure we did not breach its capacity. This, in practice, reduced the NHS to the COVID-19 health service; pushed the infection into an ill-equipped care sector; left patients to die on their own and denied care home residents vital contact with their families. The UK's excess death rate and 11 the untold misery inflicted on those who were forced to navigate J o u r n a l P r e -p r o o f their health care needs without the support of loved ones is surely evidence enough that this must not be repeated.

We must plan now for our health and social care services not to be taken hostage by COVID-19 again. Central to this should be regular testing of all staff, at least once a week; developing care pathways which draw on the considerable expertise of primary care for managing disease in the community and the triage of patients to dedicated COVID-19 facilities (e.g., Nightingale hospitals). All are essential if health and social care services are to be able to manage COVID-19 as well as the panoply of other health needs of the population. In addition, we now know with greater certainty what PPE and behaviours are necessary to reduce the risk of infection. We should, therefore, never again compel the public to feel that they can't access health care; that they must do so without the support of loved ones or put them in the position where they die alone. These should all be considered immediate and deliverable priorities. An equally important priority but which will take several years to realise is to increase the capacity of the NHS, both in terms of staff and beds. Before COVID-19 the NHS had in excess of 100,000 vacancies; the total number of hospital beds was in decline, having halved in the preceding 30 years; and our number of critical care beds per capita was far below the average for Europe as a whole. The pandemic has exploited these weaknesses and left us ill-equipped to deal with where we find ourselves.

A further priority, perhaps underpinning all others, concerns public health messaging. We know that effective messaging needs to be clear, consistent and coherent and delivered by trusted sources. However, since the beginning of the pandemic, and since the easing of lockdown, the opposite has been true. The messages have appeared confusing and contradictory: serving only to break down trust and puncture certainty regarding what is and what is not allowed, and what will and will not protect. 12, 13 This has been compounded further by the increasingly authoritarian and punitive approach that is being taken to managing the spread of COVID-19: sowing division in society at a time when our greatest weapon against this disease is to pull together. We need to act now to deliver not only effective messaging but for that messaging to lead to new and sustainable social norms by creating a sense of common purpose, collective identity and shared values. 14 We must also accept that the local lockdown 'whack a mole' experiment has failed to suppress the virus. The reasons are complex, but are very likely to be related to the continued lack of clarity in messaging, failure to offer the public tangible and achievable targets and because they blatantly undermine a sense of common purpose. It is surely time to reject this approach.

Recent surveys indicate that public opinion is out of step with policy on COVID-19. The majority do not think the pandemic has been handled well 15 and that the measures taken do not go far enough. So now is the opportune time to 'change the record'. A second national lockdown may well be necessary to break the spiral of COVID-19 infections but we should learn the lessons of the first. We should plan to support those whose mental health was most affected during the first lockdown (e.g., women 6 and the young). We should not tolerate the 'lock-up' of all society, but be prepared to make sacrifices and develop new approaches so that health and social care and education in particular can function. A second lockdown should also not be considered sufficient to contain the virus. Its very clear purpose should be to suppress the virus, but also to buy time to implement the sort of public health structures for testing, tracking, tracing and isolating that have characterised countries that are now enjoying a return to 'near normality'. In the absence of a vaccine or Operation Moonshot (neither of which may come to pass), 16 these should be the bedrock of our COVID-19 management strategy if the next lockdown is to work, and future lockdowns prevented.

The public are looking for a different approach, let's pivot and deliver this change. It's time to move towards a society able to live with COVID-19, rather than one being buffeted between ill-conceived lockdowns and the fallacy of herd immunity.

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