Leaving Lockdown — what to expect from the New Reality

As we’re leaving lockdown, I thought it would be a good time to write another article assessing where we are with coronavirus right now and what it means for us all. Brace yourself, we’re entering complex times so this is a long one! Usual caveat that I’m writing in a personal capacity as a UK-based infectious disease epidemiologist and not linked to any organization; if you want to check out my credentials you can find my CV on LinkedIn (Georgia Ladbury).

First of all, let’s address what’s on the minds on most Britons right now when it comes to following outbreak control measures. It is absolutely galling to hear the UK Health Secretary stand in front of us and instruct us that we must all do our “civic duty” whilst knowing that the upper echelons of our leadership have been doing nothing of the sort. It makes me incredibly angry to think of the huge and devastating sacrifices that people have endured over the past few months, whilst all the time senior government aides were gadding about in bluebells breaking the rules. I don’t blame anyone for an instant for thinking “That’s it, I’m done listening to this lot, from now on I’m going to follow my instincts, too”. I am as angry as you are.

But I implore you: remember who we did this for, and why. We didn’t do for the PM and his cabinet. We didn’t do it because we’re some kind of obedient serfs. We did it because we wanted to protect our loved ones and the most vulnerable of our society. And if we throw our hands up now because we want to say a giant [“INSERT SWEARWORDS OF CHOICE”] to the government, actually all we are doing is harming ourselves. If we give up now, after coming so far, many more thousands will die, including people who are dear to us. So we must keep going, hard though it is, to protect each other — in spite of whatever we might feel towards the government right now.

Your commitment to lockdown over the past weeks has without question saved thousands of lives. The aim of lockdown was to stop transmission in its tracks, to get the daily number of new cases down, to get the R down (i.e. the number of people each infected person goes on to infect). It has worked. But as well as reducing the size of the outbreak to more manageable levels, lockdown has also given us a pause during which allowed us to get better equipped to manage the virus. Our testing capacity has increased enormously, we have a far higher number of ICU beds, and loads and loads of research has been done by scientists around the world to find out more about the nature of this virus, how it affects people and how it spreads. In short: we’re in a far better position now to respond to coronavirus than were back in March.

But we are not out of the woods. Not by a very long way. The aim of lockdown was not and has never been to get rid of the virus or to reduce the risk to zero. That won’t be possible until we have herd immunity, or a vaccine, or effective targeted treatments. None of these things is going to happen in the short-term future, and given that, we now need to learn to live alongside coronavirus.

Exiting lockdown has been dubbed the “recovery” phase, but I find that phrase misleading. This isn’t “recovery” — it’s sustained response. This is the point where, rather than acting to eliminate risk by staying at home, we instead have to learn to live with the risk. Part of this is acknowledging that Covid cases and further transmission of the virus is inevitable — perhaps even desirable (if the virus turns out to be seasonal and there’s an upswing in cases in autumn and winter, it might turn out that we’re in a better position to have a population that’s been partially exposed compared to one that’s wholly susceptible). However, what the “recovery” phase does *not* mean is that we can now return to normal. Lockdown has not made the virus go away; it’s still there, and if we return to anything approaching our pre-lockdown lives and habits, the outbreak will take off again, health services will be overwhelmed, and many more people will die.

Working out how to live with risk whilst still keeping the virus under control is going to be complex. While the lockdown messages were simple to understand and to follow (yes, I’m looking at you, Dominic Cummings), this phase is going to be a much more tricky and nuanced dance. Its success will depend on three things, the first two of which you’ll have heard lots about, and the third not so much, even though it is without question the most important of all. Those things are: (1) gradual easing of restrictions; (2) a test, trace and isolate strategy; and, finally, (3) our own behaviour and choices. I’ll deal with each in turn.

(1) Gradual easing of restrictions

Lockdown shut down everything at once, in every country that implemented it. This was great for halting the virus in its tracks, but it means that it’s been hard to work out exactly what impact each of those restrictions had. If we were to lift everything at once, without question the virus would just go mad again. But if restrictions are eased a little at a time, starting with those that we think are likely not to make much difference in terms of viral transmission, and then waiting a bit to see what happens before lifting another one, this allows us to slowly ease back into a more open way of living. This is one of the reason schools and early years settings are opening as a first step out of lockdown: the growing scientific body of evidence suggests that children under 10 years are at low risk of illness and also that their role on onward transmission of the virus is limited (Alasdair Munro is a good one to follow on Twitter for regular round-ups of the science on this).

(2) Test, trace, isolate

Countless countries have now shown us that having a robust system of testing suspected cases, tracing their close contacts, and asking those contacts to self-isolate is an effective way to keep case numbers down. Test-trace-isolate works because it interrupts local chains of transmission. We know now that people can transmit coronavirus for about two days before showing any symptoms. This is why it’s been able to spread around so well, as people have infected others without knowing they’re infectious. However, if we can identify early anyone who has come into contact with a case and get them to self-isolate as a precaution, we can stop that happening — because those contacts will be “taken out” of the population before they become infectious themselves.

You’ll have heard about the app, which is a new way of contact tracing that’s not been done here before, but for now all of the contact tracing will be done by actual humans. This is simply done by interviewing each person who’s tested positive about who their close contacts have been in the recent past, and attempting to get in touch with those people to advise them to isolate. It’s worthwhile noting though, that you don’t have to rely on any official process to make test-trace-isolate happen. If you find yourself experiencing Covid symptoms (fever, a new persistent cough, or loss of sense of smell/taste), you’d do well to phone round and tell your close contacts yourself and suggest that they isolate, even before you get yourself a test — this avoids any further delays during which time your contacts could be unwittingly spreading the disease.

Contact tracing seems like a cumbersome process, but it’s actually super effective, and was used lots at the very start of the outbreak to delay the spread of the virus. However, that’s all it’s going to be able to do: slow the spread and flatten the curve. It can’t and won’t keep the virus at bay by itself. If we really want to stay on top of it, what we are dependent and reliant on is:

(3) Our own behaviour and choices

The way coronavirus spreads is pretty simple, really. It’s from people coming into contact with each other, and the droplets from the nose and mouths of an infected person being picked up by another person. This can either be through inhalation, or by touching a surface contaminated with those droplets and then touching your face. If we can prevent those things happening, we can prevent the virus spreading. So how can we do that? Well, first and foremost:

*… keep the number of people you come into close contact with as low as you possibly can. A good rule of thumb is this: if an NHS contact tracer were to call you tomorrow and ask you to make a list of all the people you have come into close contact with over the past week, would you be proud or embarrassed? Note that “close contact” is defined both by proximity (within two metres) and by time (fifteen minutes or longer). So it’s not the worst thing in the world if you have to brush past someone momentarily in the street as the pavement’s not wide enough for a 2m distance, but it does mean that if you want to go and see someone outside your household you should absolutely, without question…

*…maintain social distancing. We are by now all aching to see family and friends, and it’s great that it’s now permitted to do so to some degree, but it’s still very important to do that at distance. You may be gagging to hug your loved ones, but the best way to show them you love them is to blow them a kiss from two metres away, and also to make sure you…

*…meet up outside. The virus doesn’t spread so well in well-ventilated areas, and there is no space more well-ventilated than The Great Outdoors. This is a spectacular time of year to enjoy our parks and gardens, and fresh air and greenery is good for our mental health, so although it’s kind of a pain not to be able to go into people’s houses, it also has its benefits. Of course, although it’s fine to socialize outdoors, we can’t conduct all our lives outside so we must also try our hardest to…

*…avoid crowded/indoor spaces. If you find the shop you wanted to go in is busy and full of queues, turn right around and go back at a quieter time. Bike or walk rather than use public transport. Shop online when you can (supporting local businesses where possible). Work from home. Avoid situations where you’re in an enclosed or indoor space, and if you absolutely have to be, then…

*…use a face covering. This won’t prevent you getting infected, but it can help prevent you spreading the virus if you happen to be infected without knowing, by catching the droplets you are breathing into the air. Basically it’s like having a handkerchief tied to your face. It doesn’t have to be a disposable mask, or even a cloth mask — a simple scarf covering your nose and mouth will do. And, finally, indoor or outdoor, whenever you are out and about, be sure to…

*…wash your hands frequently. Soap kills coronavirus. If your hands become contaminated with the virus, soap will kill it, as will hand sanitizer. Hand hygiene is extremely important and all the more so when we start being out and about a lot more.

So, to summarise this new phase we’re entering into, “recovery” does not equate to unbattening the hatches and returning to life pre-Covid. This is a period of risk reduction. It’s not the rampant, raucousness you may be longing for. It’s still some time before we can go back to anything approaching those heady, carefree days of old. But we will get there.

In the meantime, live quietly, be vigilant to the risks, and make good choices. Enjoy your new-found freedoms, although they be but little. For if lockdown has taught us anything, it’s to appreciate the little things.

I’m an infectious disease epidemiologist with special interest in zoonoses, new & emerging infectious, One Health, and interdisciplinary public health research