WhenWILL it be safe to go back to normal?
Some predict this lockdown will be over in weeks. Others say it could be six months – or even longer. We ask the real experts...
IT is a crisis that many had feared and some grimly predicted. But most of us hoped such a reality would remain only in the plots of dystopian novels or Hollywood blockbusters that preyed on our deepest fears. Most of us never quite believed it could happen. Not to us.
And yet, here we are on this Easter weekend. Clear skies over the country and all of us supposed to be inside our homes, restricted to a journey of two kilometres or less. Life has come to a standstill. Our economy – like almost every economy – is flatlining. As the death toll here now exceeds 300, the Intensive Care Unit capacity in our hospitals are reaching breaking point, Gardaí are manning check-points to stop city-dwellers from escaping to the country. Welcome to our strange new reality.
The one question everyone keeps asking is: when will this all end? When can we return to normal and will normality even feel the same as it did before? The restrictions were extended to May 5 on Good Friday – but there is no guarantee that will be it. We may be living with this virus for some time, as Dr Tony Holohan, the chief medical officer, warned us this week.
‘It is a difficult decision as to when to lift restrictions and allow people back to their normal way,’ Dr Gabriel Scally, Professor of Public Health at Bristol University, told RTÉ radio during the week. ‘All eyes will be on the death toll. If that drops off, the pressure will be on to withdraw restrictions. But what’s important is how active the virus is in the community.’
For the moment, at least, there appears to be no exit strategy, no clear way back to the life we once knew. Despite Donald Trump’s nonsense about hydroxychloroquine, there are no drugs proven to work; no vaccine on the horizon that could protect us and that may be the case E for 18 months.XPERT advice is clear. As soon as the lockdown is lifted, infection rates will rise again. As Dr Anthony Fauci, a key member of the White House’s coronavirus task force, put it: ‘We don’t make the timeline. The virus makes the timeline.’
The prospect of a lengthy lockdown is – to put it mildly – uncomfortable to imagine. Concerns have been raised about how long the economy can remain in a sleepy state. Businesses have already been decimated and thousands more have joined the live register. If it goes on much longer, the entire globe could fall into a recession that would make The Great Depression look like a dress rehearsal.
Yet, there have been glimmers of hope which suggest that this period of social distancing and self-isolation is working and the infection rate is starting to slow.
Although Dr Holohan warned that the report released from the US earlier this week that Ireland had peaked wasn’t true, there is growing confidence that the social distancing strategy is taking effect; provided people don’t dismantle that progress this weekend.
A couple of weeks into the restrictions here, analysis of public contact tracing revealed that the average number of close contacts per confirmed case had decreased from 20 to less than five. In the past couple of weeks since the restrictions have become more severe, that number has decreased.
When there are no more close contacts with a case, it means, in theory, that the virus has nowhere left to go. If nobody is passing it on, there will be no new infections. Not that this means the restrictions can be lifted yet. Far from it.
Experts say that the lockdown may be working but we won’t see the full benefit immediately. That is why this weekend is key. If people, understandably fed up staring at the same four walls, take the opportunity to travel to a different part of the country, there’s every chance that we will back at square one. The behaviour of each and every one of us will determine how long the country must remain in lockdown.
Prof Sam McConkey, the head of the Department of International Health and Tropical Medicine at the Royal College of Surgeons, has been one of our more impressive voices since the crisis started and he feels that another two weeks of tough restrictions may even eradicate community transmission of Covid-19.
‘I think adding more restrictions for a week or two to really bring down transmissions might shorten the time that we have this plague among us; that our economy has stopped,’ Prof McConkey told RTÉ radio’s Drivetime during the week. He suggested: ‘Really going hell for leather and doing all we can do for the next week or two and getting the numbers down so there is no more community transmission of Covid-19.
‘We need to get unexplained community transmissions down almost to nothing before we relax and start doing everything that we’d like to do again,’ Prof McConkey said.
FOR now, we have to wait until the death and infection rate starts to fall. The big question, however, is this: what then? At the heart of our strategy has been the need to protect an already stretched health service from being overwhelmed – and it will be this which informs its next steps as we try to return to normal.
Key to every decision that the National Public Health Emergency Team has made is the intensive care capacity of our hospitals. At the start of the outbreak, there were more than 2,100 acute beds and 167 critical care beds across the country.
In what was described as ‘sobering news’ by Health Minister Simon Harris, the Mater Hospital revealed on Wednesday that its ICU was at full capacity. Dr Colman O’Loughlin, the hospital’s director of critical care medicine, admitted that most of the patients in its ICU were suffering from Covid-19 and that the hospital was fortunate that it had an extra 18 beds that can be added to its high dependency unit.
But it was a stark illustration of how grave the situation may become. Even allowing for the private hospitals now being integrated into the public system, when all the ICU beds are full, people may die because those who need critical care support, such as ventilators, can’t access it.
Prof Keith Neal, an epidemiologist from the University of Nottingham, says the global estimate is that there are roughly 1,000 infections for every death – which puts the total for the island of Ireland, to date, at over 400,000. But we don’t know whether those who have had the virus are immune to having it again.
While experts have said they have ‘every reason’ to think they might be immune, there are concerns. Other coronaviruses – including the four that cause common colds
– do not trigger lasting immunity. So, there is no model for how to proceed. The only option is for officials to analyse carefully what happens elsewhere.
That begins with China. Wuhan officially lifted its 11-week lockdown on Wednesday, with its 11 million residents being treated to a spectacular light show to signal the end of their 76 days in their homes. The rest of Hubei province had restrictions eased last week.
We know already, though, that the lockdown alone isn’t enough to combat the virus. As experts have pointed out, we ‘need to learn to live with it’.
In China, some shops, cinemas and businesses were abruptly closed again – suggesting relaxed measures may have prompted further infections.
A second wave was also reported in Hong Kong after the two-week quarantine for travellers was lifted and students returned at the end of term.
The situation in China is being monitored closely, with Prof McConkey pointing out that once they closed the economy for two weeks, transmission rates dropped.
HOWEVER, a report by the Imperial College in London shows that – ironically – the more successful the attempt to contain the spread of infection, the more likely there is to be a significant second peak later in the year.
Some experts hope one way out lies in the much-maligned herd immunity idea. This is when a large enough proportion of a population have had an infection, or been vaccinated. The disease ceases to spread easily – and essentially dies out. But of course, this relies on infection leading to lasting immunity, which, as we have said, isn’t yet known.
Prof Neal said if the herd immunity theory held, then ‘countries like Spain and Italy, which struggled to control their outbreaks, or Sweden and Singapore where shops and bars stayed open, could have a lower second wave of infection.’
If a second wave does come to Ireland – as is predicted for the late autumn – it could be even more catastrophic, coinciding with the annual flu season, which already places huge pressure on our health service. Aside from herd immunity the only other definitive way out is a vaccine. Neither are quick solutions.
One possible exit strategy, which has been supported by a recent Harvard study, involves turning the restrictions on and off intermittently for two years – or until a vaccine becomes available. The aim would be to manage demand on health services by having several smaller peaks of infection rather than one large one.
Dr Holohan hinted at such a strategy during Tuesday’s press briefing. ‘There might be a scenario where measures are in place until the disease gets back below a certain threshold and relaxation happens. If there is an increase, restrictions might need to be tightened again and that’s a scenario that could go on for a period of time,’ he said.
‘We’re not close to having a vaccine at this point and maybe measures like that would have to exist until we got to that point.’
Herd immunity would continue to build during the periods when lockdowns were relaxed, so the infection rate would slow and there would be increasingly lengthy periods between the restrictions. But many are reluctant to impose intermittent lockdowns simply because people would struggle to adhere to them, with some experts believing it would not work due to human nature.
Ivo Vlaev, Prof of Behavioural Science at Warwick Business School, says: ‘Intermittent lockdown is not a good idea. We are creatures of habit and everchanging guidelines may create problems. If the Government suddenly lifts the current restrictions and we are all free to do as we choose, we will flow back into our old way of life in many respects, as our ingrained habits will resurface.’
There has been a suggestion that the Government may look to relax restrictions in stages, following the Chinese model. And a close eye will also be kept on Denmark, Austria and the Czech Republic – three EU countries who have gradually lifted restrictions and are bringing their economy back to life on a phased basis, sector by sector.
ASTUDY modelling the effects of ending the Wuhan lockdown, from the London School of Hygiene and Tropical Medicine, recommended the staggered approach. It found reintroducing the workforce over four weeks, and then reopening schools, could delay a second peak of infections by two months making it easier to manage.
Another solution is lifting the measures in less-affected regions for up to six months at a time, as recommended by the Scientific Pandemic Influenza Group on Modelling. But ultimately, lifting restrictions relies on knowing who has been infected.
This might mean mass antibody testing, and even the issuing of ‘immunity certificates’ already used in Germany. No reliable antibody tests are yet available.
A factor complicating our approach in Ireland is the two jurisdictions on the island. Experts such as Prof McConkey and Dr Scally have repeatedly called for a coordinated all-island approach since this crisis started. And it may be difficult to ease the restrictions if in two weeks’ time, the curve has been flattened in the south, but is still on an upward trajectory north of the border.
For now, though, the critical thing on both sides of the border is to get the numbers down, so that we can all return to something resembling our normal life. If infection rates have fallen to a reasonable level by the middle of May, the Government may be able to introduce less intensive measures including swab-testing any new cases and rigorous contact tracing in a bid to isolate any remaining virus.
Swab testing was at 1,200 a day last week but the HSE told this newspaper last week that they want to scale that up to 4,500. Phone apps could be used to track people’s contacts should they become infected, as has been done in South Korea.
Of course, it is still too early even to claim that South Korea has got it right. As Anders Tegnell, Sweden’s state epidemiologist, told BBC Newsnight recently: ‘I don’t think anyone can be seriously confident of getting this right, since it’s never happened before.’
In time, we may have to learn how to balance the need to ‘flatten the curve’ with the need to live our lives and resuscitate the economy. But for the moment, it looks like we are in this for the long haul.
Still, as we munch on chocolate today, we should remember that, as in fiction and film, this pandemic will eventually end. What we don’t know yet is when.