A group of experts have written to the UK CMOs and GCSA, expressing concern about a second wave of covid-19

Professor Chris Whitty; CMO, England
Dr Frank Atherton; CMO, Wales
Dr Gregor Ian Smith; CMO, Scotland
Dr Michael McBride; CMO, Northern Ireland
Professor Patrick Vallance; Chief Scientific Adviser, 

Dear CMOs 

We write to express our grave concern about the emerging second wave of covid-19. Based on our public health experience and our understanding of the SARS-CoV-2 virus, we ask you to note the following: 

1. We strongly support your continuing efforts to suppress the virus across the entire population, rather than adopt a policy of segmentation or shielding the vulnerable until “herd immunity” has developed. This is because:
   a) While covid-19 has different incidence and outcome in different groups, deaths have occurred in all age, gender and racial/ethnic groups and in people with no pre-existing medical conditions. Long Covid (symptoms extending for weeks or months after covid-19) is a debilitating disease affecting tens of thousands of people in UK, and can occur in previously young and healthy individuals.
   b) Society is an open system. To cut a cohort of “vulnerable” people off from “non-vulnerable” or “less vulnerable” is likely to prove practically impossible, especially for disadvantaged groups (e.g. those living in cramped housing and multi-generational households). Many grandparents are looking after children sent home from school while parents are at work.
   c) The goal of “herd immunity” rests on the unproven assumption that re-infection will not occur. We simply do not know whether immunity will wane over months or years in those who have had covid-19.
   d) Despite claims to the contrary from some quarters, there are no examples of a segmentation-and-shielding policy having worked in any country.Notwithstanding our opposition to a policy of segmentation-and-shielding, we strongly support measures that will provide additional protection to those in care homes and other vulnerable groups.
2. We share the desire of many citizens to return to “normality”. However, we believe that the pandemic is following complex system dynamics and will be best controlled by adaptive measures which respond to the day-to-day and week-to-week changes in cases. “Normality” is likely to be a compromise for some time to come. We will need to balance suppressing the virus with minimising restrictions and impacts on economy and society. This is the balance that every country is trying to find—and every country is having to make trade-offs. This might mean moving flexibly between (say) 90% normality and 60% normality. We believe that rather than absolute measures (lockdown or release), we should take a more relativistic approach of more relaxation/more stringency depending on control of the virus.
3. Controlling the virus and re-starting the economy are linked objectives; achieving the former will catalyse the latter.  Conversely, even if policies to promote economic recovery which cut across public health objectives appear successful in the short term, they may be detrimental in the long term.
4. As evidence accumulates for airborne transmission of the SARS-CoV-2 virus, measures which would help control the virus while also promoting economic recovery include mandating face coverings in crowded indoor spaces, improving ventilation (especially of schools and workplaces), continuing to require social distancing, and continuing to discourage large indoor gatherings, especially when vocalisation is involved. With measures like these, much of society will be able to function effectively while keeping the risk of transmission relatively low.
5. As we move beyond the acute phase of the pandemic, it is important to restore routine medical appointments (e.g. for long-term condition review and patient concerns that may indicate new cancers). We believe that a combination of remote appointments (online, phone and video) plus face-to-face appointments with appropriate personal protective equipment will allow this to happen safely. We recommend a communication campaign to inform the public that the NHS is now open for most routine business.
6. In a complex system, we should not expect to see a simple, linear and statistically significant relationship between any specific policy intervention and a particular desired outcome. Rather, several different policy measures may each contribute to controlling the virus in ways that require complex analytic tools and rich case explanations to elucidate.
7. While it is always helpful to have more data and more evidence, we caution that in this complex and fast-moving pandemic, certainty is likely to remain elusive. “Facts” will be differently valued and differently interpreted by different experts and different interest groups. A research finding that is declared “best evidence” or “robust evidence” by one expert will be considered marginal or flawed by another expert. It is more important than ever to consider multiple perspectives on the issues and encourage interdisciplinary debate and peer review. While government must continue to support research, some decisions—as you will be well aware—will need to be made pragmatically in the face of uncertainty.  

We thank you for your continuing efforts to get us through the pandemic. 

Trisha Greenhalgh, Professor of Primary Care Health Sciences, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

Competing interests: None declared

Signed on behalf of full list of signatories — please see list below.