What if there is no Covid-19 vaccine?

As most of the world starts to ease lockdown, it seems timely to ask the question of “What next?”  Many will believe that the new normal is just a stepping stone back to the old normal, but the reality is that Covid-19 has not gone away.  Nor are we likely to see a vaccine in the near future, for which read years.  As epidemiologist Mark Woolhouse told New Scientist in early April: “I do not think waiting for a vaccine should be dignified with the word ‘strategy’. It’s not a strategy, it’s a hope.”  Which raises the question of what the strategy is?

As long as the virus is around, it will continue to infect and kill.  Unlike the Spanish Flu pandemic, it seems to be more discriminating, predominantly resulting in the death of those already at risk.  It’s almost as if it’s sticking two fingers in the air to the last century of medical advancement, saying that for all of the machines we now have which go “ping”, the medical profession is as helpless as it was back in 1918.

What that means is that the elderly and those with underlying conditions will remain at risk and society will probably try to be over-zealous in protecting them.  Without a vaccine, here in the UK, the implication is that we will probably never see the Queen make a public appearance.  In the US, Donald Trump, assuming he doesn’t succumb to the virus, will still be promoting quack cures as he steps down at the end of his second term, and anyone with a parent in a care home may never get to hug or kiss them again, which is a strange definition of care. 

If we take the vaccine out of the picture, there are three basic strategies, as shown below.  The first – the blue line, is to just get on and ignore it.  It’s the pre-vaccine approach that was the only option that existed during the Spanish flu.  Millions died, and the world saw dead bodies on the streets, but the only option was to accept that in the name of herd immunity.  During the Spanish flu pandemic, that resulted in a first wave, a horrendous second wave, and smaller third wave which signalled the end of the pandemic.

With a century of medical PR telling us that our health systems can cure us, that’s no longer an acceptable option, so both politicians and doctors have to agree on an acceptable number of deaths and then try and manage infection rates so they don’t exceed that limit.  The politically set limit is indicated by the dashed yellow line, which essentially tries to balance the number of ICU beds and ventilators against the number of people needing them.  If you can keep under that, your health systems may be severely stressed, but they shouldn’t break down.  To manage that, the Government instigates lockdowns and social isolation to limit the number of infections.  The expectation (and it is only an expectation at the moment) is that it will result in successive waves of infection (as shown by the green line), between which life can return to some sort of normal.  However, each new wave will probably require a return to lockdown, with all of the social and economic damage which accompanies it.  When you decide to ease and reimpose lockdown is still something of a gamble, as this is all new.  It’s also important to realise that the cycle could run for years.

The third approach, indicated by the red line, is total suppression, where you rigorously track and trace, isolating all potential infections until you have wiped it out.  It’s what South Korea is doing very effectively at the moment.  The problem is that you end up with a country which is free of the virus, but is a sitting target for new infections from outside.  It effectively means quarantine for everyone coming into the country until a vaccine is found.  In the short term that may not be a problem, but it increasingly isolates a country from the rest of the world.  With South Korea’s only land border being the demilitarised zone to North Korea, that’s feasible.  Tourism only accounts for 2.7% of its GDP, so it could remain shut down with limited impact.  Few other countries have that luxury.

That conflict around travel is being played out today at an international level, with the EU calling for borders to be opened, while individual countries are imposing quarantine restrictions on travellers.  The international pressure for a return to open borders is largely fuelled by the airline industry which is playing its twin cards of bankruptcy and massive redundancies.  Air travel will probably return before it should, with the inevitable recriminations from countries who will blame others for starting a second wave of infection.  But it’s not the most important aspect of travel.  It’s obscuring a more local dilemma, where traditional holiday destinations are trying to balance the need for tourist income against the Covid-19 infections which may accompany those tourists.

In the UK, London is seen as the hotbed of infection, with estimates of around 20% of the population having contracted it.  In much of the rest of the country, that figure is thought to be closer to 5%.  As London gets back of work, with the double whammy of the return to mass public transport and the Dominic Cummings “don’t give a damn about rules” approach to Government advice, that number will probably head towards 40% by the end of the summer and the 60% which allegedly infers herd immunity by Christmas.  Of course, we don’t know whether herd immunity exists for Covid-19.  It could be that we can catch it multiple times, possibly with equally severe consequences.  Any sensible testing regime would retest everyone who has had a positive test every fortnight for at least a year in order to find out.  Unfortunately, our testing regime has largely been driven by whoever shouts loudest, with little obvious scientific common sense applied to generating useful learning.

London is not alone in its status.  The infection levels in cities around the world is captured in the diagram below which shows the estimated percentage of the population of major cities who have acquired antibodies to Covid-19.

We need a strategy for the millions at risk if we assume that there will be no vaccine in their lifetime, which means respecting them above headline mortality numbers.

Cities have another factor which pushes up infection rates, which is their population distribution.  They generally have younger populations, which are more likely to be asymptomatic and thus increase the spread of the virus.  A report by the Centre for Cities estimated that UK cities are home to 62% of people aged 18 – 34, but only 46% of those aged over 65.  The elderly, typically the more vulnerable as far as Covid-19 is concerned, have shown a long-standing desire to retire to the coast, with the oldest UK populations in Blackpool, Worthing,  Bournemouth and Southend – all popular holiday resorts.

This is why we need to think about local strategies.  Comparing the UK, or anywhere else’s infection rate with other countries is no longer very useful – we are where we are.  Only time will tell which country’s containment strategy produced the best balance of mortality, economic damage and social disruption.  The more immediate concern should be how to manage the regions and those most at risk as our largest cities come back to life and head toward herd immunity.

There’s not an easy answer.  Those living outside major cities will want to restrict movement.  Those within will want more freedom and a return to life as normal.  Those most at risk will probably divide into two camps – the fearful, whose only option is to self-isolate for years, and the pragmatic, who will feel that isolation represents no meaningful form of life, preferring to go out and live it, rather than ossifying in front of their TV.  If they are independent, they have that choice.  Once institutionalised, or in a care home, the worry is that they have that choice removed from them.  Our leaders tend to obsess about targets, in this case the number of new infections and deaths each day, regardless of how reaching that target might affect individual’s daily existence.

These are difficult questions, but we need to address them.  We may not know how to handle Covid-19, as this is new to everyone, but we should know how to treat society.  Too many groups have been excluded in the past.  Our strategy should not be to use this pandemic to add the elderly and vulnerable to that list. 

Unlike international air travel, there is no large lobby group to raise the position of the million or more who fall into this category within the UK – they only make a quiet whisper composed of tens of thousands of personal tragedies.  Politicians could start by asking their own parents how they expect to live their next few years, as should we all.  Otherwise, we infantilise them by assuming we know better than they do.  For all of them, the clock is ticking.  It is immoral to ignore that fact in the hope that a vaccine will arrive.  Unless we acknowledge this dilemma, we risk scaring a generation into retreating from the rest of their lives.  We have no right to do that.