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Should countries aim for elimination in the covid-19 pandemic?

BMJ 2020; 370 doi: (Published 09 September 2020) Cite this as: BMJ 2020;370:m3410

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Re: Should countries aim for elimination in the covid-19 pandemic?

Dear Editor,

When considering whether countries should aim for elimination in the COVID-19 pandemic, there are essentially two questions to answer.

1. Is elimination possible at all?
2. Do the benefits of achieving elimination outweigh the costs of pursuing it?

If the answer to either question is negative then it is obvious that elimination would not be a valid approach. On the first question there is much doubt, but for the purposes of discussion let us assume that it is possible to achieve elimination.

The focus then becomes on how to achieve elimination, and whether the measures required would cause more suffering than would be saved by achieving the goal. A simple cost/benefit analysis in theory, but remarkably difficult to do in practice because there is so much disagreement over the negative effects of the virus and the negative effects of the measures required. With so little consensus it becomes important to focus on the features of the virus that are most widely accepted, so that our starting point can at least be agreed.

From the early days of this virus two things quickly became apparent. Firstly that it is capable of very rapid spread amongst people showing no symptoms, and secondly that certain groups of the population appear far more likely to suffer from it than others. These are the essential characteristics of this virus.

Although the extent of asymptomatic spread is still debated and although 'Long COVID' has emerged as an issue, it seems that the essential characteristics are still largely accepted. It is these essential characteristics that must dictate our response to the virus.

The first characteristic (rapid 'invisible' spread) makes it extremely difficult to put in place targeted measures. Restrictions which target people showing symptoms do not suffice, so the steps that have been taken start from the point that everyone is a potential carrier/spreader. The healthy majority are treated identically to the sick minority in order to prevent the sickness spreading. This in turn leads many to perceive the reaction as disproportionate in respect of the restriction of liberty that is involved. The economic, social and corresponding health costs are hard to calculate, but it is generally accepted now that lockdown and other restrictive measures exert a heavy toll on almost all groups in society, with certain more vulnerable groups worst affected.

All of this means that in order to achieve elimination we must battle the virus in the area that it is hardest to defeat - ease of spread - and we must employ measures that we are hugely uncomfortable with, and which may end up costing more than is gained by victory. Given the problems with elimination we need to at least consider the alternatives.

The other essential characteristic of the virus gives us a clue as to an alternative strategy. This is the idea of specifically protecting the most vulnerable while the less vulnerable are left to carry on, taking the chance of infection.

Although there is logic to freeing up the majority of society to act as previously while protection efforts are concentrated on those most in need, there have been very few practical suggestions as to how this could feasibly be achieved. Isolation of the vulnerable seems to create or exacerbate the same problems as lockdown for those affected, and would force families to split in a way that the current household bubble approach does not. The question of who is vulnerable is also a difficult one to answer. We know that broadly risk increases with age and co-morbitities, but drawing arbitrary lines at a certain age or for people with certain conditions fails to recognise that there are huge disparities between individuals within the same age range. It would be hard to justify that a - say - 64 year old one day should be free to act as they choose, but isolated on the day they turn 65. And is that something society would want to enforce upon people?

If the route to elimination and isolation of the vulnerable both cause too much suffering then what next? Practical suggestions have been largely absent amongst the torrent of voices who question the lockdown approach. But some do exist. One such example is the targeted protection advocated by the greenbandredband system. This approach proposes that all adults be given the right to choose whether to class themselves as vulnerable or low risk. No arbitrary lines, just a personal choice based on personal risk assessment. From there very simple rules exist. For those who classify themselves as vulnerable, distancing/protection measures similar to those in place currently would be maintained. The low risk would also follow these rules when interacting with the vulnerable. But where low risk individuals mixed with each other, they would not be bound by distancing rules.

This very simple system offers multiple benefits compared to the status quo, the isolation of the vulnerable or compared to an unmitigated spread of the virus.

Firstly it removes most of the concerns around the erosion of traditional freedoms or human rights. The system is based on choice, and this choice is a free one offered to all individuals. With choice comes flexibility and the ability to recognise that each situation is nuanced. For instance if a person who would otherwise be low risk happens to be in regular close contact with (e.g. lives with) a vulnerable individual then they might choose to classify themselves as vulnerable in order not to put their housemate at greater risk.

Secondly it protects the vulnerable. On the basis of the first essential virus characteristic, spread of the virus amongst the lower risk (self identified) would almost certainly increase compared to the current situation, but on the basis of the second essential characteristic, this would not result in a significant increase in hospitalisations or suffering. The current concern that increased cases amongst the young will inevitably lead to increased cases amongst the old would be addressed by the system's basic principle that the low risk must respect protection measures in their interaction with the vulnerable.

Thirdly it offers the prospect of increased freedom for the low risk to return to something closer to a pre-virus existence. Economic recovery will be assisted by more people being able to return to work and businesses being able to increase their capacity for those who are content to take the risk of infection.

Finally it buys us time by making it easier for people to 'follow the rules'. The world is waiting for an effective vaccine, but the wait is a painful one. The longer people are asked to make sacrifices - particularly people who are in the less vulnerable groups - the less accepting they become and the more splintered society becomes. The greenbandredband system still requires all individuals to moderate their behaviour, but the restrictions are far less intrusive and far easier to understand than the current mishmash of constantly changing and inconsistent rules and guidance. By making the rules easier to stick to and easier to understand they are far more likely to gain general and long term acceptance.

By instituting a system such as greenbandredband, the government could move into an advisory role. Rather than prohibit or allow, the government could focus on informing people so that they were best equipped to make sensible and considered assessments of their risk. These might well change as circumstances and scientific knowledge evolve, but the system allows for people to change their mind and reclassify themselves into the other category.

Whereas all other proposals for a response to the virus require considerable amounts of money to be spent, the greenbandredband system requires virtually no investment and could be put in place extremely quickly. All that is required is for people to understand the rules and to clearly communicate their position with others.

All details of how the system would work can be found on the website

Competing interests: No competing interests

12 September 2020
Steven Sieff
Veterinary Practice Manager
Hertfordshire, UK